OASIS Alert

Published on Wed Jul 31, 2013 PDF

Don’t hesitate to report ‘needs supervision’ even when your patient lives alone.

Understanding the nuances of your choices for answering M1860 — Ambulation/Locomotion is essential. Make sure you don’t miss out on this opportunity to take credit for your patient’s improvement and possibly boost your agency’s reimbursement.

Establish the Basics

OASIS item M1860 asks you to indicate your patient’s current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.

Your response options for M1860 are:

0 — Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device);

1 — With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings;

2 — Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces;

3 — Able to walk only with the supervision or assistance of another person at all times;

4 — Chairfast, unable to ambulate but is able to wheel self independently;

5 — Chairfast, unable to ambulate and is unable to wheel self; or

6 — Bedfast, unable to ambulate or be up in a chair.

Timepoints: You’ll complete M1860 at start of care, resumption of care, follow-up, and discharge not to an inpatient facility.

Know these Key Differences

Before you can select a response for M1860, you’ll need to know the definitions of bedfast versus chairfast versus ambulatory, says Annette Lee, RN, MS, HCS-D, COS-C, AHIMA ICD-10 Trainer with Redmond, Wash.-based OASIS Answers. Be certain you understand the specifics before you make your choice.

Know the Difference Between Bedfast and Chairfast

Bedfast: The patient is either medically restricted, or not safe out of bed. Select response “6” for bedfast patients.

Chairfast: The patient can tolerate being out of bed, but can perform no safe ambulation. She may be able to shuffle a few steps to a bedside chair or to make a transfer, but no more than that, Lee says.

Be sure to consider whether the patient can locomote herself safely, Lee says. “Running into walls, running over your foot, tripping over the cat — that’s not safe.” And the intent of M1860 is to determine what the patient can do safely. It’s not just performance, she says.

Bottom line: The chairfast patient can’t ambulate safely, even with a device and human assistance. Select response “4” or “5” for chairfast patients, depending on whether the patient is able to wheel himself.

Be sure to read the response-specific instructions when considering responses “4” and “5,” says Karen Vance, OTR, supervising consultant with BKD in Colorado Springs, Colo. Clinicians sometimes think a patient can’t score as chairfast because they can stand at the sink or they can transfer. That’s not correct, she says.

Dig into the Details with Ambulatory Patients

The ambulatory patient can locomote safely either independently or with assistance. If your patient is ambulatory, you’ll need to choose from four different possible responses (0-3).

Mistake: Don’t be tempted to scan down the left side of responses 0-3 to read just the first few words of the responses, cautions Vance. Making your selection based on the opening phrases “with use of one-handed device” or “requires use of two-handed device” will lead to inaccurate data.

Read through the whole response, Vance says. Don’t base your answer on whether the patient uses a cane or a walker, she says.

For example: Response “1” says the patient uses a one-handed device, but the rest of the answer indicates that he is completely independent, Lee says. That means the patient is able to walk on even and uneven surfaces.

“If he can walk with a one-handed device, but not on uneven surfaces, ‘1’ isn’t an appropriate response,” Vance says. He may need a two-handed device to ambulate safely.

Response “2” starts out by saying the patient requires a two-handed device such as a walker to ambulate safely, but the rest of the response indicates that he needs human assistance with uneven surfaces and stairs. “Remember, supervision and assistance doesn’t have to be hands-on. Verbal cues and reminders are also considered assistance,” Vance says.

“A patient is a ‘2’ if they need intermittent assistance, whether they use a cane, a walker, or no device,” Lee says.

Problem: Many clinicians are uncomfortable reporting response “3,” Lee says. They don’t want to say the patient needs assistance when he doesn’t have anyone to provide it, she says. “They worry it sounds like abandonment.”

One major M1860 mistake is when the documentation doesn’t support the answer when the clinician must choose between “2” and “3,” Vance says. This is most likely to occur when nurses do the comprehensive assessment and therapy is also seeing the patient. If the therapy documentation shows the patient isn’t safe, selecting “2” is the wrong way to go.

Clinicians shouldn’t fear reporting response “3,” Lee says. “It could be that the patient needs a device and doesn’t have one yet,” she says. But you can’t make an assumption about how a device will impact a patient’s ambulation ability when the patient doesn’t yet have that device. If your patient is “furniture surfing” and unsteady, until you get her a device and she can use it safely, she’s a “3,” she says.

What to do: When the patient scores a “3”, you have two options, Lee says. The patient may not be appropriate for admission because he isn’t safe at home. Or you may be able to talk to the family, get therapy involved and care plan to help get the patient to where he is safe at home.