Quick And Easy OASIS Documentation Tips

To carry out an accurate assessment, you need to understand the OASIS questions and use appropriate strategies. Read the OASIS Implementation Manual, Attachment B, which gives you item-by-item tips for each OASIS question.

MO230 Primary Diagnosis. Choose the diagnosis that reflects the chief reason for home care. This diagnosis must match the primary diagnosis listed on the POT.

MO240 Other Diagnoses. If the primary reason for home care is a manifestation code, use this code in the first slot of MO240 and list the etiology code in MO230.

MO250 Therapies the patient receives at home. Only include those therapies the patient is receiving or will receive as a result of this assessment at home.

MO390 Vision. Assess the patient's vision with corrective lenses if the patient normally wears them.

MO420 Frequency of pain interfering with patient's activity or movement. Identify frequency of pain interfering with activity with treatment if prescribed.

MO440 Does this patient have a skin lesion or open wound? A skin lesion is an alteration in skin integrity. It does not include: anything ending with 'ostomy' or peripheral IV sites. It does include: central lines, PICC lines, implanted infusion devices, venous access devices, bruises, age spots, sores, skin tears, burns, ulcers, rashes, surgical incisions with sutures or staples, pin sites, crusts, persistent redness without a break in the skin, etc.

MO450 Current # of pressure ulcers at each stage. The bed of the ulcer must be visible to stage the ulcer. If the ulcer is covered with eschar, necrotic tissue or a non-removable dressing, it cannot be staged. Do not reverse stage 3 or 4 granulating pressure ulcers.

MO482 Does this patient have a surgical wound? A surgical wound includes: orthopedic pin sites, central line sites, stapled or sutured incisions, incisions with approximated edges and a scab, debrided graft sites, wounds with drains, Mediport sites and other implanted infusion or venous access devices.

MO520 Urinary incontinence or presence of urinary catheter. If patient has anuria or an ostomy for urinary drainage, mark response #0. If patient is incontinent AT ALL, mark response #1. If patient requires the use of a urinary catheter, mark response #2. If patient is both incontinent and requires the use of a urinary catheter, mark response #2 and follow the skip pattern.

MO530 When does urinary incontinence occur? Any incontinence that occurs during the day should be marked with response #2.

MO640 - MO820 ADLs and IADLs. To assess the patient's ADL and IADL status, use direct observation supplemented by interview.

MO650 - MO660 Ability to dress upper and lower body. If patient uses dressing aids, assess ability using aids. If patient requires standby assistance for safety or verbal cueing, mark response #2. Consider physical limitations at the time of assessment and pain as well as clothing routinely worn.

MO670 Bathing. Assess the patient's ability to bathe the entire body and possible assistance to safely bathe. Use response #2 or #3 for patients requiring standby assistance or verbal cueing. If patient cannot use the bath or shower because they are restricted by an MD order or unable to access second floor tub or shower due to restriction from stair climbing, use response #4 or #5.

MO680 Toileting. Assess the patient's ability to safely get to and from the toilet or beside commode. This does not include ability to perform personal hygiene.

MO690 Transferring. Assess the patient's ability to transfer safely for the three transfers indicated. Only use the response #2 if the patient can both bear weight and pivot.

MO700 Ambulation/Locomotion. Assess ability to walk safely once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces. If the patient requires standby assistance or verbal cuing, use response #1 or #2. A patient who is able to take one or two steps to transfer but is otherwise unable to ambulate, should be considered chair-fast, so choose #3 or #4.

MO826 For all Medicare fee-for-service patients. The total of all physical, occupational, and speech-language pathology combined visits must be reasonably estimated.

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