OASIS Alert

No peeking at previous answers when describing current status.

When selecting your OASIS responses, be careful not to let past data influence your choice.

“Responses to items documenting a patient’s current status should be based on independent observation of the patient’s condition and ability at the time of the assessment without referring back to prior assessments,” the Centers for Medicare & Medicaid Services says in the conventions for completing OASIS-C.

That means no looking back to prior assessments when an item asks you to report a patient’s current status. Instead, you should make an independent observation about your patient’s condition at that particular time point. Looking back at previous assessments could influence your response and have a negative impact on accuracy.

Exception: Certain process measure items do require you to reference the documentation for prior care. When you see the phrase “since the previous OASIS assessment” in an item, it’s an indication that you can reference previous records as you determine your response.

“Since the previous OASIS assessment” means “at the time of, or since, the time of the most recent SOC, ROC or FU OASIS assessment,” CMS explains. You’ll find this instruction included in items that are looking for historical data rather than assessment data as well as certain process measure items.

For example: M1510 — Heart Failure follow-up, asks “If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond?” To answer this question, you’ll need to review the clinical record including physical assessment data, weight trends, and clinical notes, “at the time of the previous OASIS assessment or since that time,” CMS advises.