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Care Documents

 

Complete an OASIS C-2


This guide is to show how to Complete an OASIS-C2

 

See CMS.gov for final guidance manual for the OASIS-C2 

 

Note: Start of Care and Recertification OASIS will automatically generate a Plan of Care (POC) when signed and completed by the clinician. Resumption of Care OASIS will only generate a POC if it occurs within the last five days of an episode where it takes the place of the recertification.

 

Select the desired OASIS under TASKS within MY SCHEDULE/TASKS, the PATIENT CHART, or the SCHEDULE CENTER.

 

To get to My Schedule/Tasks from the dashboard, click on the More tab on the Dashboard:

 

Select the desired OASIS by clicking on blue task label. (Recerts will not show in list if they are greater than two weeks out from when the date list is viewed)

 

 

To get to the Patients Charts:

oasis 3

 

Select the desired OASIS by clicking on blue task label:

 

To get to the Schedule Center:

oasis 4

 

 

Select the desired OASIS by clicking on blue task label:

 

Once the desired OASIS is opened, all necessary documentation can be entered. For specific sections of the OASIS, you will need the following information to understand how to complete the OASIS in AgencyCore:

 

The first page is the demographics page and contains info as it is entered on the patient’s profile. This page is almost exclusively OASIS questions and will have boxes that are green in color.

 

Note: Throughout the document, the Green boxes indicate that OASIS questions are contained within. See the MOO question number for guidance.

 

While working on the OASIS, if the clinician is unsure what a particular M question is asking, he or she can get more info by clicking on the specific OASIS number pertaining to the question or clicking on the associated question mark:

 

This will open a separate box with a description of the item intent and clarification of the appropriate response.

 

Once the information on the first page has been entered, the typical clinician has the option to Save, Save & Continue (move to the next page), or Save & Exit. These actions are available on every page except the final page.

 

On the second page (Patient History & Diagnosis), additional colors will be noted on the documentation boxes.  See the OASIS -C2 Overview for detailed OASIS breakdown.

 

Throughout the OASIS, those in the blue color are general info or physical assessment boxes.

 

Those that are grey in color indicate that information is a Plan of Care (POC) question and that information will flow to the corresponding section of the POC.

 

There are two ways to add a diagnosis description and code, one is to type in the ICD-10 code, select the appropriate code and label in the drop down by clicking on it which will populate both into the OASIS.

 

The diagnosis label may also be typed in and the appropriate label/code selected from the drop-down.

 

Select a SAVE option on the page, as previously discussed, when the page is completed and the clinician wants to proceed to the next page, opts to Save, as needed.

 

Continue working through the document, completing all OASIS questions, all applicable assessment questions, and all applicable interventions/goals for the patient. Once the clinician has reached the last page (Orders for Disciplines and Treatment), the options will be to SaveSave & Check for Errors, or Save & Exit.

 

Errors:

 

If there are any errors on OASIS questions, they will be listed with the corresponding M number and a brief explanation of the issue. There may also be warnings listed, these are different from errors, as they don’t specifically relate to an OASIS question but alert to procedure or compliance issues.

 

To correct a listed issue, click on the item you wish to correct.

 

This will take you directly to the page of the item that needs correcting. (Example: The above errors relate episode timing. Clicking on the error will take you directly to the episode timing page to correct the errors.)

 

Once you make the appropriate corrections, you can click Check for Errors from either the top or the bottom of the page. You do not have to return to the last page of the document to perform this function.

 

Whereas having OASIS errors will prevent you from signing off on the OASIS, warnings will not. However, warnings are provided to help prevent compliance deficiencies and should be treated as priority items. Unless you have certain billing permissions you will not see the section for billing data on the signature page. You will see the section for selecting a G-Code.

 

Once you have cleared all errors and warnings, the next step is to run the OASIS Scrubber. This is designed to check for logical and clinical inconsistencies to help reduce audit risks.

tcb_OASIS_scrubber HHG

 

The following image is merely an example of some of the inconsistencies that may be found. Your information may be different.

 

This example is due to one answer in the document indicating the patient has incontinence, but a second question indicating the patient does not. This will need to be corrected in the OASIS. If the patient is not incontinent then M1018 needs to be changed. However, M1610 will need to be changed if the patient is incontinent. The inconsistencies related to the patients ADLs/IADLs will require corrections to the given answers, if not accurate, or will require additional documentation to validate the answers given if that is how the patient functions. Again, these are examples and your responses may vary.

 

Once any needed corrections are made, the OASIS scrubber can be run additional times to validate changes. If no inconsistencies are found, then the document will appear as below.

 

Note: there may be situations where inconsistencies will need to remain due to patient functionality, so not all OASIS will be free of those flags.

Now the OASIS is ready to be signed and submitted to QA. Two remaining items need to be addressed before entering the signature. First, the appropriate G-Code needs to be selected. There are 4 G-Code options for nursing as indicated below.

 

Note: Selecting the correct G-Code will be determined by the primary type of care provided during the visit in addition to OASIS data collection. This also helps to determine the type of care the patient is to receive. See the Home Health Manual on CMS.gov for the criteria pertaining to each G-Code type.

 

If the patient is not traditional fee-for-service Medicare, you may need to select “Use default value defined in payor profile” in lieu of a G-Code as that payor may use different codes. Please check with your administrator, director of nursing, or appropriate office staff to determine if this option needs to be selected.

 

The second and final step needed prior to signing the OASIS is to select the plan of care (POC) type. Medicare and Medicaid both use the OASIS document. You have the option to select a typical 485 POC or a Medicaid POC. Which one is to be used is determined by the primary payor for that patient’s care. Please check with your administrator, director of nursing, or appropriate office staff to determine which option needs to be selected if you are not certain.

tcb_OASIS_poc selection

 

Enter the electronic signature (if the electronic signature is not correct, it will need to be reset: (How do I reset my signature?), the time in and time out of the visit, and the date the document is signed.

tcb_OASIS signature and finish

 

The OASIS will then be “locked” (clinician will not be able to make changes) and Submitted (Pending QA Review).

tcb_OASIS_pending QA

 

At that time, a POC will also be generated. This document will be in Submitted (Pending QA Review) status.

 

OASIS Scrubber


Axxess has used the OASIS Scrubber powered by Home Health Gold for several years to audit OASIS for Clinical Inconsistencies, Coding Inconsistencies, Fatal Audits and CMS Warnings.

 

Now you have the ability to customize the scrubber to trigger audits and alerts for many more categories.

 

To review currently selected scrubber categories and add the new scrubber categories as desired, you will need to hover over Admin and select Manage Company Information. After entering your electronic signature and selecting proceed, you will be logged into the Manage Company Information screen.

Manage Company Info

 

Select the tab on the left labeled Scrubber Information.

 

After selecting or deselecting the preferred Scrubber Categories, click on Submit Request to save the changes.

 

A green box should appear in the top right corner stating "Scrubber info is saved successfully".

Success Notification

 

The first 4 listings shown below are the original audits which previously have automatically flagged without user intervention. These will be selected by default in the Scrubber Information page but those with access to manage company info will be able to choose to leave them selected, add other options, or deselect, as they may choose to do so.

 

CLINICAL

The Clinical Audits, called an Inconsistency Flag, focus on possible inconsistencies between OASIS responses on a particular assessment. These may or may not need to be altered depending on the inconsistency and patient functionality.

 

CODING

Diagnosis Coding Audits focus on possible inconsistencies between a diagnosis and other OASIS items. They also identify instances where the diagnoses may not conform to coding rules, particularly as they relate to PPS Reimbursement.

3. tcb_scrubber_coding4. tcb_scrubber_coding

 

FATAL

Fatal Audits focus on the rules CMS uses to reject OASIS Assessments. They apply to all assessments an agency plans to submit to CMS. Fatal audits show on both the signature page and on the full audit page. Fatal audit errors will typically not allow you to complete the OASIS until corrected.

7. tcb_scrubber_fatal sig page

6. tcb_scrubber_fatal on pdf

 

CMS WARNING

The CMS Warning Audits are derived from CMS consistency rules for submitting OASIS data. They consist of audits that generate a warning but do not cause rejections. This will also appear on the signature page of the OASIS with a yellow triangle symbol beside it.

5. tcb_scrubber_cms warning

 

ADDITIONAL CATEGORIES NOW AVAILABLE TO SELECT FROM:

 

GROUPER VALIDITY

The Grouper Validity audits identify OASIS responses or omissions that block the generation of a valid HIPPS score. Such omissions may also create a "Fatal" Audit. Typically this is going to generate an error on the signature page as well and will not allow the OASIS to be completed, if not completed properly.

14. tcb_scrubber_grouper

 

PROCESS MEASURES

The Process Measure Audits identify responses to process items that signify that "best practice" has not been followed. These issues will eventually reflect on the agency via their CASPER reports.

9. tcb_scrubber_process measure

 

OUTCOME POTENTIAL

Outcome Potential Audits show the 7 OASIS items where improvement over the course of care is measured. These audits are designed to help an agency identify situations where they have potentially under-assessed a patient's needs, assessing the patient as doing so well at SOC or ROC that later ratings cannot reflect improvement.

11. tcb_scrubber_outcomes

 

COMPLIANCE RISK

The Compliance Risk Audits focus on instances where the pattern of OASIS responses and planned care patterns has strong potential for triggering a post-payment review.

10. tcb_scrubber_compliance risk

 

POTENTIALLY AVOIDABLE EVENTS

The Potentially Avoidable Events Audits identify responses on an assessment that will trigger a Potentially Avoidable Event flag at CMS.

13. tcb_scrubber_avoidable

 

READMISSION RISK

The Readmission Flags show, for a particular OASIS assessment, responses which are common to patients who are especially likely to experience an early return to the hospital.

12. tcb_scrubber_readmit risk

 

 

Complete a Plan of Care (POC)


If all applicable fields within a SOC OASIS Assessment or a Recertification OASIS Assessment are completed, a Plan of Care will be automatically generated with all applicable data pre-populated.

 

Note: A ROC (Resumption of Care) will generate a POC only when it is completed in the last five days of an episode as it takes the place of the Recertification. Otherwise, an entirely new POC is not created, as only new orders are needed when a patient is resumed.

 

To manually complete a POC, it first has to be scheduled. You can do this in the Schedule Center. Go to the Schedule tab and choose the Schedule Center.

Schedule Center

 

Find the patient for whom the 485/POC is needed. Select the date to schedule the POC. You may also click on the Show Scheduler tab. Then choose the Orders/Care Plans tab and select the Plan of Treatment/Care task.

Find Patient

 

Choose the user to whom you want to assign the task.

 

Click Save to add the POC to the schedule. Now the Plan of Treatment/Care is scheduled and can be edited by clicking on the blue hyperlinked task name in the Schedule Center.

Schedule 485

 

My Schedule TasksMy Scheduled TasksNote: If returning to the POC at a later time, you can also find it on the Patient’s Chart (Go to the Patients tab, choose Patient’s Charts and find patient by name), or in My Scheduled Tasks found under the Home tab and the Schedule tab.

 

 

When filling out the Plan of Treatment/Care, the first page will contain information from the patient’s profile.

Plan of Care

 

As you scroll down, you will see the Medications section. To add new or change medication to the POC, click the Add/Edit Medications button.

Plan of Care Add Medications

 

Another window will pop up, click the + (plus) sign to add a new medication. A new blank line will populate for you to fill out with the medication information. Enter the start date for the medication, part of the medication name, and click Search.

Add Medications

 

This will pull a list of medications that start with the letters entered. Select the appropriate medication name and dosage to populate it to that field.

Add Medications

 

This will automatically trigger the Classification field. Selecting the desired classification will populate that field, as well.

Add Medications

 

Now, the Frequency and Route can be added.

Add Medications

 

Once all fields are completed and all new or changed medications have been added, select Insert, then select Save & Close to update the medication list. All medications from the medication profile will show in the Update Medication screen, but they can be removed after all new medications have been added and saved.

 

Note: if the POC is being created to accompany a Resumption of Care, only new or changed medications should be added to the POC. If you delete the medications from the update screen, it will delete them from the medication profile completely. Wait until the new additions have been saved, then delete the medications that were previously included in an active POC or for which new orders have already been obtained.

 

Example: the first Coumadin was included in the original 485 created for the episode. They need to be deleted after saving the changes to the medication profile as they are not new or changed. You can delete by selecting the row that is to be removed and click backspace on your keyboard or click the Add/Edit Medications button and update accordingly.

Add Medications

 

Only the new Coumadin will be included in the NEW POC.

Add Medications

 

Moving on to diagnosis in the POC, there are two ways to add these details (Principal, Surgical, or Other Pertinent).

Plan of Care

 

 

Principal Diagnosis1. Type in the ICD-9 (ICD-10 starting October 1, 2015) and select the correct option in the drop-down. Example: Atrial Fibrillation

 

2. Principal DiagnosisType in the ICD-9 (ICD-10 starting October 1, 2015) and select the correct option in the drop-down list. Example: I48.91

 

Either option will populate the description and code to the appropriate boxes. Onset/Exacerbation and applicable date can then be entered.

 

Once all necessary information has been entered into the POC in the corresponding fields, the document can then be saved for additional review and update, or if the clinician is done entering POC information, then he/she can enter his/her electronic signature and select Complete.

Plan of Care

 

You will receive a confirmation notification that your Plan of Care has been successfully saved.

Success Notification

 

The document should then be in a Completed (Pending QA) status for review and approval.

485 Plan of Care

 

 

Complete 60-day Summary


To complete a 60-Day Summary it must first be scheduled. See 60-Day Summary in the Help Center to schedule your 60-Day Summary, if it is not already scheduled.

My Schedule Tasks

 

You can locate the 60-Day Summary, if it is assigned to you, under My Schedule/Tasks under the Home tab.

My Schedule

 

You can also locate the 60-Day Summary in the Patient’s Chart.

Patient Charts

60 day Summary

 

Or you can find the 60-Day Summary in the Schedule Center.

Schedule Center

Schedule Center

 

From any of these areas in AgencyCore, click on the blue hyperlinked text to open the 60-day Summary document. The highest and lowest vital signs (including weight and blood sugar) entered for visits scheduled during the episode will automatically populate to the 60-Day Summary. In some rare instances, an MD will receive the 60-Day Summary as an order. This option is available by selecting Send as an order at the top of the screen.

Send as an order

 

Once all applicable fields are completed, there is an option to Save the document and return to it later for final completion.

 

Note: Only one person can sign the document electronically. If other employee signatures are needed on the document then it will need to be printed out and signed manually.

 

If fully completed, the electronic signature of the primary person completing the document will be entered and Complete selected to submit to QA.

 

 

Complete a Discharge OASIS Assessment


An OASIS Discharge may be completed from several locations:

 

My Schedule/Tasks:

My Schedule

 

 

To navigate to My Schedule/Tasks, hover over either the Home or Schedule tabs. Choose My Schedule/Tasks.

My Schedule

 

To locate from the Dashboard, go to My Scheduled tasks.

My Scheduled Tasks

Electronic SIgnature

 

Schedule Center: 

 

Hover over the Schedule tab and choose Schedule Center.

Schedule Center

 

My Monthly Calendar:

 

Hover over the Home tab and choose My Monthly Calendar. Navigate to the appropriate month and find the OASIS Discharge.

Monthly Calendar

 

Patient Charts:

 

Find Patient Charts under the Patients tab. Find the patient you are looking to discharge. Under the patient demographics, you will see a task for the OASIS Discharge.

Patient Charts

 

In all of these options, select the blue hyperlinked OASIS Discharge to open the document. Some data will automatically pull from the patient profile. If you have the appropriate permission, you will have the option to load a previous OASIS assessment.

Load Assessment

 

Fill in all applicable data in the document, and at the bottom of each page, select from Save (remains on the current page), Save & Continue (advances to the next page) or Save & Exit (closes the document). There is also the option to Check for Errors; however, please note that the earlier in the document you select to check for errors the greater the number of errors that will be generated.

 

Note: the Approve button is permission-based and will only appear if the user has the appropriate permission. This allows the individual granted that permission to approve the document, once it is completed, without it going to QA.

 

Continue working through each page, selecting the desired Save option.

 

On the page labeled Discharge, please note that if the patient was hospitalized, or transferred to any type of facility, the standard OASIS-C2 Discharge is not the correct type of document, as a facility admission requires an OASIS-C2 Transfer/Transfer Discharge. An OASIS-C2 Discharge is used for routine discharge such as when the patient has met goals, declines further home care, or other situations that do not result in an inpatient admission. (You and/or your agency must determine the appropriate document type).

Discharge C2

 

When the OASIS Discharge is completely filled out, select Save & Check for Errors to validate the document.

 

If errors are found, the display will look similar to this.

Errors

 

Clicking on any one of the listed errors will take you directly to the page on which the MO question is located. Locate the MO question associated with the listed error and make the appropriate selection to correct the question.

 

Once all errors are corrected, the screen will display the option to sign the document. Before signing the document, run the OASIS Scrubber.

Oasis checker

 

Note: the OASIS Scrubber checks the OASIS for logical and clinical inconsistencies, which are likely to trigger a chart audit. It is only intended to be used as guidance and should be interpreted as such. No liability is assumed for changes made by the clinician or administrator due to the information contained in the OASIS Scrubber document.

 

The following is intended as a demonstration of the types of inconsistencies that may be flagged by the scrubber — your results may be different.

Audit

 

If the documentation in the OASIS is correct, the flags can be disregarded.

 

Note: it is important that any potential flags have thorough documentation to support the findings and to explain inconsistencies within the OASIS in the event a chart audit is requested by the payor. Otherwise, make corrections as appropriate and rerun the OASIS Scrubber.

 

If all documentation is complete, then the OASIS can be signed off and submitted to QA. You still have the option to Save the document and complete it at a later time. Otherwise, enter your electronic signature, the date of signature, and select Finish. The OASIS will now be in a Completed (Pending QA Review) status unless the clinician has the permission to Bypass QA; in that case, the document will be in a Completed (Export Ready) status.

Discharge OASIS

Index