Home Health & Hospice Week

Be sure your documentation backs up your OASIS responses and resulting claims, especially with these often missed items.

Vision impairment (M1200). Your clinical documentation must be consistent with any problems identified in this item. If your patient’s vision scores as partially or severely impaired, you’ll want to show evidence of it in the medical record. Good documentation includes details such as "provided large print reading materials," "made suggestions about improving the lighting for safety" or comments indicating that you considered vision problems and their impact on medication management.

It is also important to include any diagnosis- or problem-related issue that causes vision impairment, Maxim says. Good documentation describes why the patient’s vision is impaired and just how such impairment will impact the plan of care.

Cognitive functioning (M1700). When caring for a patient who is confused, you should document the patient’s mental state on each visit. Your documentation should always reflect the reason you’re in the home. You should evaluate and monitor for safety, medication management, and other basic care issues every visit. Be sure to document this.

Bowel and bladder incontinence (M1610/1620). Assumptions that elderly patients are often incontinent lead to this problem being inadequately documented. Be sure to include incontinence in the treatment plan and document it in the record, when applicable.

You may need to address chronic incontinence only once, but you’ll still want to include the details in the medical record. Your documentation should include the length of time the incontinence has existed, information about the cause, supplies you are using, and preventive education to avoid skin breakdown. Document new problems such as recent incontinence of unknown origin or incontinence related to mobility issues more frequently as part of the treatment plan. Be sure to include the details of what you’re doing to address the issue.

Note: For more information, analysis, and tips on OASIS, subscribe to Eli’s OASIS Alert at www.aapc.com/codes/coding-newsletters/my-oasis-alert.