OASIS Alert

Look to situational cues as you consider each OASIS item.

The approach you take when determining your OASIS responses should vary depending on the item.

As a general rule, you should combine observation and interview when assessing your patient’s condition in regard to an OASIS item.

For example: The response-specific instructions for M1850 — Transferring advise you to take a combined observation/interview approach with the patient or caregiver as you determine the most accurate response for this item.

This approach includes asking the patient about transferring ability and observing the patient during transfers to determine the amount of assistance she requires to complete a safe transfer from bed to chair.

Mistake: Skipping the observation step is a sure way to put a dent in your OASIS accuracy. When you ask the patient or his family about his ability, you may get an exaggerated response. Patients who are afraid they may not be able to remain at home may downplay their difficulties.

You also run the risk that the patient may not fully understand the questions you ask.

To get a better understanding of your patient’s condition, be sure to observe the patient as well. The more you actually see, the greater accuracy your OASIS responses will have.

Best bet: When you’re assessing a patient’s physiologic or functional health status, direct observation is the Center for Medicare & Medicaid’s preferred strategy.

But in some cases, you may also need to use other item-particular strategies when answering OASIS questions. For example, you can look at the hospital discharge summary when you’re determining an answer to M1010 — Inpatient diagnosis at Start of Care. And at Transfer or Discharge, you’ll look to the care notes to determine whether a physician-ordered intervention was implemented as you answer M2400 — Intervention Synopsis.