OASIS-Central

Homecare episodes can be tracked by “events”—admission, resumption, new orders, recertification, discharge. Clinical record evaluation should address each one.

Admission and recertification

• Ensure that all required documentation is present, whether via hard copy or as indicated by electronic processing of the admission.
• Conduct reviews related to OASIS in conjunction with review of other record documents. OASIS should not be viewed as simply answers to the data items, but as one part of the broader patient assessment. Focus on high-scoring data items and validate them by reviewing the additional information obtained through the comprehensive assessment. An agency may want to develop parameters to consider when reviewing each case-mix data item, or it may choose to use commercial decision-support products that provide such feedback. In either case, the most important management function is to address incongruities and poorly supported items.
• Evaluate for appropriate start of care (SOC) and certification dates. The SOC date must coincide with the first billable visit, and the SOC OASIS must not occur prior to the SOC. Validate the appropriate time frame for the recertification OASIS.
• At admission, compare the referral orders with the OASIS and the 485/plan of care to validate the appropriateness of admission and evidence of skilled, medically necessary care as defined by regulations. This is an important step because it provides a point of comparison between the referral source’s expectations and the current picture of the patient. Making this comparison may help identify areas of overlooked need and delays in initiating all disciplines, and it may be instrumental in highlighting additional concerns.

This is an excerpt from the article “Agency Competence: Clinical Records, Part II”, which originally appeared in the July  2010 edition of Homecare Administrator. Learn more about Homecare Administrator here!