OASIS-Central

Agency Competence: Clinical Records, Part II

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. [...]

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A patient is recertified two days before the end of the certification period. One day before the end of the certification period the patient is admitted to acute care for three days. When discharged from acute care, should we do a resumption of care or a start of care?

Q:  A patient is recertified two days before the end of the certification period. One day before the end of the certification period the patient is admitted to acute care for three days. When discharged from acute care, should we do a resumption of care or a start of care? A: You didn’t mention when [...]

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I received a doctor’s referral on 02/17/2010 and the patient refused to be seen on the 19th. They instead requested to be seen on the 20th. The MD was notified and was OK with the change of date. Can I answer M0102 with 20th?

Q: I received a doctor’s referral on 02/17/2010 and the patient refused to be seen on the 19th. They instead requested to be seen on the 20th. The MD was notified and was OK with the change of date. Can I answer M0102 with 20th? A: Yes, in this situation, the physician-ordered start of care [...]

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I understand that many agencies are creating either a new form or verbal start of care order that incorporates M2250. Is this really necessary?

Q: I understand that many agencies are creating either a new form or verbal start of care order that incorporates M2250. Is this really necessary? Not all items in M2250 are going to be relevant (answered “yes”) for every patient. At start of care, when we report to the physician our findings and the projected [...]

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If at start of care the answer to M1610 is 1- Patient is incontinent and then at discharge it’s 2- Patient requires a urinary catheter, what does our OBQI score show?

Q: If at start of care the answer to M1610 is 1- Patient is incontinent and then at discharge the answer is 2- Patient requires a urinary catheter, does our OBQI score show improvement, decline, or no change? A: The patient would show a decline in urinary incontinence. Although improvement in urinary incontinence remains an [...]

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Is a transfer/discharge assessment required if the follow-up was completed in the five-day window?

Q: Is a transfer/discharge assessment required if the follow-up was completed in the five-day window and the patient goes into the hospital, following the completion of the recertification, also within the same five-day window? A: A transfer assessment would be required if the patient was admitted to an inpatient facility for a period of 24 [...]

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