OASIS Alert

Q: Is it acceptable for an agency to use per diem nurses to do recert assessments when regular staff nurses are too busy, but then have the per diem nurse report the assessment data to the primary case manager for that patient, who then completes the OASIS paperwork?

A: From a legal standpoint, this practice may compromise the integrity of the medical record, advises Burtonsville, MD-based health care attorney Elizabeth Hogue. Imagine yourself on a witness stand in a courtroom, she suggests, and imagine the opposing attorney asking if it's true that you completed and signed the form, even though you did not assess the patient.

Even more importantly, completing an OASIS assessment in this way is not in accordance with either professional standards or the Centers for Medicare & Medicaid Services' requirements, a CMS spokesperson tells Eli. The recertification OASIS assessment "is to be completed by only one qualified clinician and that clinician must complete the assessment during an actual visit to the patient's home," the spokesperson admonishes. (Refer to OASIS User's Manual, rev.12/2002, on page 8.29 under response specific instructions and assessment strategies.)

Remember the children's game "Gossip," Hogue counsels. When the information was passed from person to person, inevitably what came out at the other end was different from the initial statement. Information relayed from one person to another for documentation purposes can be forgotten, not appropriately assessed or otherwise incorrectly reported to the primary nurse, the CMS spokesperson adds.