There is an overall new look and additional functionality in the OASIS assessments.
- The blue sections indicate assessments and special assessment sections.
- The Gray sections are for those locators that are on the new plan of care.
- Some of the special assessments sections also will appear on the new plan of care.
- The green sections are for answering the OASIS questions.
- There is a new purple section for the interventions.
- The NON-OASIS assessments are identical except for Medicare requirements, i.e. OASIS questions
- Added a new NON-OASIS ROC and transfer
- Added a No Visit Discharge OASIS [CoP-484.55(d)]
- Added one Transfer OASIS
- Added OASIS Other-Follow up to document significant changes in condition as per the regulations [CoP-484.55(d)]
Blue Section: Physical Assessment
- Head to toe assessment sections are blue for easier identification and to speed up charting by enabling the clinician to perform problem based focused documentation. [CoP-484.55]
- A new response option “No problems identified” has been added so if no problem is identified, clinicians can move quicker through assessment without having to address the remaining options in the body system.
- If a problem is identified, robust charting options are available to assist the clinician with clinical documentation improvement to augment the need for skilled care. [CoP-484.55(a)]
- Added a new psycho-social section with extensive documentation of variables that may impact the patient’s attainment of goals. [CoP-484.55(c)(1)]
Blue Sections: Special Assessments
- There are several special assessment sections:
- Risk Assessments
- Braden Scale
- Nutritional Health Screen
- Validated MAHC Fall risk assessment
- Two new risk assessments added to assist the agency in identifying and developing plans of care for patients at risk for hospital readmission and emergency department visits. [CoP-484.60(a)(2)]
- Acute Care Hospitalization Risk Assessment (HHQI)- for patients with no hospitalization, 30 days past hospitalization or recent discharge
- SHM BOOST 8P’s- for a patient’s coming directly out of the hospital
Green Section: OASIS Items
- OASIS sections streamlined and easier to read.
- Diagnosis from the New Patient form during intake, flow to diagnosis section
- Added ability to easily search for diagnosis codes
- Removed dates as per the OASIS guidelines from diagnosis section
- Built-in guidance for OASIS questions
Gray Section: Plan of Care Locators
- Plan of Care locators are embedded within the OASIS to complete the Plan of Care orders as the clinician completes assessment documentation. [CoP-484.60(a)(2)]
- Clinician signature remains on the Plan of Care once the OASIS is signed
Purple Section: Interventions
- Problem statements added to help the clinician streamline documentation and focus on the individualized plan of care development [CoP-484.60(a)(2)]
When a problem statement is chosen, the narrative text will flow to the Plan of Care [CoP-484.60(a)(2)]
- All narratives are customizable to address the individual and continuing needs of the patient [CoP-484.55(c)(2), 484.55(c)(3)
- Clinicians are assisted with documenting home-bound narrative based on disease process and functional status relationship (narrative text will flow to the Plan of Care) [CoP-484.55]
- Clinicians are assisted with easier identification of and documentation of medical necessity; need for skilled care (narrative text will flow to the Plan of Care) [CoP-484.55]
- Goals include measurable outcomes [CoP-484.60]
- Goals are based upon medical diagnosis, physician’s orders, comprehensive assessment and patient input [CoP-484.60(a)(1)
- Included continued ability to use templates
When a problem is chosen, further documentation prompts are presented to assist the clinician with clinical documentation improvement. Cognitive overload is diminished as clinician only see this additional information when needed.
Therapy Evaluation Section
- The Physical, Speech and Occupational Therapy evaluations are now embedded into the OASIS documentation [CoP-484.55(b)(3)]
- Quicker documentation of the Manual Muscle Test/ROM and other functional testing
- Side by side evaluation of prior vs current functional status in subsequent assessments [CoP-484.55(c)(3)]
- Individualized functional goals and prompts to meet guideline [CoP-484.60(a)(1)]
- Therapy Tool Box with access to multiple objective assessments as needed
- Easy care planning with therapy specific interventions
Summary of Care Section
- Contains discipline need and frequency [CoP-484.60(a)(2)]
- Ability to add additional physicians on the case [CoP-484.60(c)(3)(i)]
- Physician certification/re-certification statements
- Need for oral explanation of Patient Rights by 2nd visit if language barrier impeded ability on admit [CoP-484.50(a)(3)]
- Able to document F2F addendum information
- Infection control [CoP-484.70(a)]
- Patient’s area of learning interest and personal healthcare goal(s) [CoP-484.55(c)(2)]
- Plan of Care review with client/representative [CoP-484.55(c)(7)]
- Patient Strengths and Care Preference [CoP-484.55(c)(2); 484.55(c)(6)]
- Documentation of patient representative and communication [CoP-484.55(c)(7)]
- First visit interventions (i.e notice of rights, etc.) [CoP-484.50(a)(1)]
- Ability to enter HHA Careplan [CoP-484.80(g)(2)]
- Ability to perform sup visits on subsequent OASIS assessments [CoP-484.75]