OASIS Alert

10 ways to protect yourself.

What you don't write in your assessment may be as important as what you do write.

While you're trying to figure out what the OASIS assessment questions mean and how to best answer them, remember that the OASIS form is also a crucial part of the patient's medical record.

And the patient's medical record is a legal document, experts emphasize. Besides reminding clinicians of what was done and how the patient responded, the medical record documents the type and quality of health care you provided to the patient.

Whether a fiscal intermediary is challenging the care in a medical review or the court is questioning it in a malpractice lawsuit, the patient's medical record can help or hurt you, depending on its quality. As you complete your next OASIS assessment, keep these commandments in mind:

1. Documentation is as important as the care you provide. If you didn't document a thorough assessment, the person reviewing the record will assume you didn't do one.

2. Sloppy or incomplete records indicate you provide sloppy or incomplete care. Take the point of view of someone looking for problems and look at the record to spot weak areas. "All you need is one disgruntled family member and a plaintiff's attorney looking for a good payday to make what seems like an inconsequential error into something quite costly," advises attorney Virginia Caudill with Indianapolis-based Gilliland & Caudill.

3. Focus on OASIS accuracy. Inaccurate documentation on the OASIS assessment may put the patient in the wrong home health resource group. This could result in your agency being overpaid or underpaid for the care you provide. It also could lead to fraud and abuse charges, suggests Burtonsville, MD-based attorney Elizabeth Hogue.

4. Support your clinical decisions with documentation. When you look back to explain or justify what you did, it is hard to recreate the thought processes, experts agree. And if an intermediary or attorney questions your decision, you'll be glad you took the time to document.

5. Be sure the record is legible. To know you provided the care, the reader must first be able to read the record. Use only abbreviations from your agency's approved list.

6. Remember you are not a reporter. Use your professional judgment when answering OASIS questions, rather than just transcribing what the patient said. If the answers you record are inconsistent with the observations you document, the fiscal intermediary could choose whatever pays less. This may even result in an obviously homebound patient being declared not homebound, Hogue says. Nursing notes plus the OASIS form increase the likelihood that a surveyor pressed for time will find the information to establish compliance, Caudill counsels.

7. Don't procrastinate. Document as close as possible to the time you provide the care or make the observation. Courts give contemporaneous notes more weight because they are more likely to be accurate, experts say.

And if you make an error, don't scribble over it or white it out, Caudill warns. Just draw a single line through the erroneous material, mark it as an error and initial it, she instructs.

8. Avoid brevity. Even though the OASIS assessment seems to require only the briefest of answers, failing to note additional information to explain your assessment may harm you. You don't transmit this additional material to the FI, but it is available for surveyors, medical reviewers, patients and attorneys to read, Hogue says. Separate notations supporting your assessment let you "show your math," Caudill explains.

9. Stick to the facts. Avoid including frustrations or value judgments about the patient of family in the medical record, experts say.

10. Don't stop with the assessment. Your ongoing documentation should continue to update and report on problems such as pain, wound condition or homebound status. And don't just rely on the patient's answers--continue to make your own observations, adds Beth Carpenter with Beth Carpenter & Associates in Lake Barrington, IL.