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Documentation – Record Keeping including OASIS

Documentation – Record Keeping including OASIS


Clinical Record Contents

The Agency maintains a confidential clinical record for each patient/client admitted to care. Closed or previously discharged records do not become current files if the patient is readmitted to services.  The clinical record includes the following information:

  1. Identifying Data

The identifying data includes:

      1. the patient’s/client’s name, address, telephone number, age, sex
      2. emergency contact and or legal representative
      3. copies of any advance directives, if applicable
      4. name of primary caregiver(s) if any
      5. source and date of referral
      6. admission and discharge dates from the hospital or other institution, if applicable
      7. name and phone number of the physician or allowed practitioner responsible for care
      8. diagnosis(es) and or medical conditions
      9. physician’s order including medications, diet, treatment, and activity, as applicable
      10. signed release of information and other documents for protected health information, if applicable
      11. admission and informed consent documents
      12. assessment of the home, if applicable
      13. initial assessment and any ongoing assessments if applicable
      14. a written plan of service/care, as applicable
      15. evidence of coordination of service/care provided by the organization with others who may be providing service/care
      16. signed and dated admission and clinical/visit notes that are written the day the service is rendered and incorporated at least weekly
      17. copies of summary reports sent to physicians, as applicable
      18. client/patient/family response to service/care provided, including goal progress
      19. discharge summary as applicable
  1. Assessment
    1. Each professional caregiver who is active in a patient/client’s care is responsible for assessing the patient/client.
    2. An initial assessment is to be done on admission. A copy of the assessment is kept in the clinical record. The initial assessment documentation must be submitted within 48 hours after admission.
  2. Physician’s Orders (check your agency policy if this is needed)
    1. A verbal or written physician order is obtained before starting care. A verbal order is followed by a written order signed by the physician.  When indicated by Agency policy, written physician’s orders are obtained and signed by the physician within thirty (30) days after admission to the Agency.  These orders are to be renewed as necessary and a minimum of every 2 months for patients/clients receiving skilled care, and every 6 months for patients/clients not receiving skilled care.
    2. Physician’s orders are to cover the following:
      • Name
      • Prognosis
      • Treatment
      • All pertinent diagnoses
      • Medications
  1. Change of Physician’s Orders
    • Changes in orders that occur before the orders are renewed are to be documented in the clinical record and a written request is to be sent to obtain the orders in writing. Any changes in orders are signed & in the patient’s chart in the timeframe reference above.
    • When returned from the physician, the orders are to be filed in the clinical record.
    • If applicable, a reassessment and renewal of physician’s orders are done whenever necessary and at least every 60 days.
  2. Care Plan
    • A Care Plan is to be developed by the registered professional nurse doing the initial assessment.
    • The Care Plan is developed on admission to service and updated and signed by a registered professional nurse as needed and at least every 60 days for patients/clients receiving skilled services.
    • The Care Plan is to include a description of each service, required treatments and procedures, medications, diet regimens, and frequency of service.
  3. Home Health Aide Care Plan
    • Each patient receiving service from a Home Health Aide, or the paraprofessional performing Home Health Aide duties, is to have a care plan developed by the coordinating nurse or professional therapist at the onset of service. It is to be updated as needed and at least every 60 days for patients receiving skilled services.
    • The plan will specify the scope, frequency, and duration of services.
    • The plan is signed by the RN/therapist and reviewed with the Aide and patient.
  4. Record of Supervision of Aides
    • A supervisory note is to be written on admission and every 14 days for Home Health Aides, or the paraprofessional performing Home Health Aide duties, providing service to patients/client.
    • Supervisory notes are to contain the following:
      • Patient/client condition
      • Supervision of Aide
      • Reference to any pertinent information
      • Competency of Aide
      • Problems, interventions, outcomes
      • On-the-job training
      • Interaction with patient/client, Aide, and family
      • Evaluation of relationship among patient/client, field staff, and family
      • Review of care plan with patient/client, Aide, and family
  • The notes are to be legible and signed with full name and title.
  1. Progress Notes
    • Progress notes are used to record each patient/client visit or phone contact. The notes are to include a summary of patient/client status, response to plan of care and any contacts with family, informal supports, and other community resources.
    • Each caregiver is responsible for recording the care delivered.
    • Each caregiver signs and dates notes with her/his full name and title enters the date of the notation, and indicates the type of contact made.
    • The progress notes are also to be used to record:
      • Observations and reports made by Aides
      • The patient/client’s receipt of information regarding his/her rights
      • Accidents and grievances
      • Visits made to supervise Aides
  1. Activity Report/ Daily Timesheet
    • The Aide is to check off those services implemented. Each entry is to be signed and dated by both the Aide and the patient/client.
  2. Release of Medical Information
    • The patient/client is to sign a form to authorize the release of medical information to the Agency so that appropriate care can be delivered.
  3. Discharge Summary
    • A discharge summary is to be completed on all patients/clients discharged from the Agency. It is to be completed within 30 days of discharge and is to include:
      • Patient/client status upon discharge
      • Recommendations and referral for any follow-up care, if needed.
    • Required Documentation
      • All required documentation must be completed and, in the patient,/client record within fourteen (14) days of service delivery.
      • To ensure that the highest quality of coordinated home health care is provided to all patients/clients through direct communication of all involved disciplines, we have established effective interchange, reporting, and coordinated patent/client evaluation through patient/client case conferences.
        • Patient/client case conferences are conducted every 60 days and as needed. An interdisciplinary case conference can be requested by any member of the staff who identifies a need for in-depth interdisciplinary intervention to successfully provide the care that an individual patient/client requires.  All individuals involved in the patient/client’s care will be requested to attend, including the patient/client/caregivers/family.
        • The staff member who is the primary nurse is responsible for the initiation, coordination, and documentation of the conference.
    • Subjects discussed in patient/client case conferences include, but are not limited to, the following:
      • Patient/client assessment of physical status and/or changes in condition,
      • Patient/client intervention for all disciplines,
      • Development/implementation of patient/client care plans and teaching plans,
      • Evaluation of patient/client treatment plans and progress toward goals,
      • Review of appropriateness of continued delivery of services to patients/clients, and
      • Discharge planning.
  • An Interdisciplinary Case Conference form is completed by the primary RN. All identified issues, plans for implementation of correction, and the individuals responsible for implementation will be noted on the form.
    • The original is filed in the patient/client’s clinical record.
    • Copies are given to all who attend the conference.
  • The physician will be notified of any changes in the patient’s plan of care.
  • Follow-up and outcomes will be noted by visit staff in progress notes. All clinicians involved in patient/client care, including contract Agency personnel, will have access to the plan of care.
  • Documentation Errors:
    • In the event a documentation error occurs, the staff member involved is required to draw one line across the documentation involved being sure that the incorrect documentation can still be read. The word error should be written above the line drawn and initiated.  The correct documentation should follow.
  • Late Entries:
    • When an entry is made out of sequence, a bracketed (*) is placed in the margin at the front of the line in which it should appear, along with the location in the record where the late entry may he found.
    • The late entry is prefixed by the term LATE ENTRY in uppercase letters as well as the page, date, and line of the patient/client record where the entry should appear.
    • The notation in the patient/client record is signed by the person making it along with the date and time of the entry.
  1. Home Record Contents:
    1. A record will be maintained in the home for all patients. The Record will be clean and orderly and will consist of the following and the home record will have Agency name and appropriate phone numbers on the front of the folder:
      • Bill of Rights and Responsibilities, including complaint/grievance information (state Hot Line number, hours of operation, who to call)
      • Home Health Aide care plan
      • Emergency Plan (state Hot Line number, hours of operation, who to call)
      • Abuse, neglect, and exploitation
      • Medication Profile (including narcotics forms)
      • Glucometer log (as appropriate)
      • Safety information
      • Wound care order (if appropriate)
      • Teaching information when appropriate
      • Vital signs
    2. The patient’s home record is updated as appropriate.


OUTCOME AND ASSESSMENT INFORMATION SET (OASIS)(Medicare/Medicaid certified agencies only)

Purpose: To ensure accurate collection of the OASIS data set at specific time points.

Policy: The Outcome and Assessment Information Set (OASIS) will be completed by an RN (or PT, OT, or ST if the case is therapy only) and at specific time points on all Medicare/Medicaid adult home care patients.

Procedure: The OASIS data set contains questions that span different time points, with only certain questions applying to each time point. The time points are:

      1. Start of Care
      2. Resumption of care following an inpatient facility stay
      3. Follow-up, recertify (every 56-60 days) or significant change in condition
      4. Discharge (not to inpatient facility) or Death at home
      5. Transfer to inpatient facility with or without Agency discharge
      6. Start of Care Assessment/Resumption of Care

All new Medicare/Medicaid patients admitted to home health services are to have the Start of Care assessment of the OASIS data set completed. The Agency Start of Care Assessment questionnaire contains all required Medicare questions as well as other added questions to allow for a comprehensive patient assessment.

The Resumption of Care Assessment/OASIS data set is completed on resumption of care following an inpatient facility stay.  A hospital stay, which is admitted for 24 hours or more and is not admitted for only diagnostic procedures, requires a transfer OASIS and resumption of care OASIS.

The Resumption of Care OASIS is to be completed within 2 days of being aware that the patient has returned home, and homecare has been ordered to resume.

Follow-up (every 56-60 days)/ Recertification/ Significant change in condition

The Follow-up assessment of the OASIS data set questionnaire contains all Medicare/Medicaid mandatory questions as well as other added questions to allow for a comprehensive assessment. It is used for recertification and significant change in condition.

Discharge (not to an inpatient facility)

The Discharge Assessment of the OASIS data set questionnaire contains all Medicare/Medicaid mandatory questions as well as other added questions to allow for a comprehensive assessment. This form is also used for death at home. The Oasis discharge summary is sent to the physician.

Transfer to Inpatient Facility (with or without Agency discharge)

      1. The Transfer to Inpatient Facility Assessment of the OASIS data set questionnaire contains all required Medicare/Medicaid questions. The Transfer OASIS is completed within 48 hours of becoming aware that the patient was admitted to a facility for more than 24 hours to receive treatment. The OASIS transfer summary is sent to the facility to which the patient is transferred and to the physician of record (as noted on the 485). The summary will contain documentation that the summary was sent to the receiving facility and physician of record.
      2. The Discharge Assessment questionnaire will be completed for all routine discharges as well as non-routine discharges other than inpatient admissions.
      3. The Discharge Assessment questionnaire can only be completed for patients who have had the Start of Care Assessment questionnaire completed.
      4. A physician’s verbal order for discharge must be completed and signed by the physician.

Transfer to Inpatient Facility (with or without Agency discharge)

      1. The Transfer to Inpatient Facility Assessment of the OASIS data set questionnaire contains all required Medicare/Medicaid questions.
      2. The Transfer to Inpatient Facility Assessment will be completed for any inpatient (hospital stay with or without discharge) from the Agency. The Interruption of Service form will be completed if the patient is admitted to the inpatient facility and not discharged from the Agency.
      3. The Transfer to Inpatient Facility Assessment will be completed for any inpatient stay with discharge from the Agency.
      4. If the original Transfer to Inpatient Facility Assessment is completed without discharge from the Agency and the patient is not discharged from an inpatient facility prior to recertification, then a new Transfer to Inpatient Facility OASIS (complete M0100) with discharge from the Agency.
      5. A Post Hospital Assessment Order form is required to continue services when the patient is discharged from an inpatient facility and was not originally discharged from the Agency.

Partial Discharge Assessment

      1. The Partial Discharge Assessment of the OASIS data set questionnaire contains all required Medicare/Medicaid questions.
      2. The Partial Discharge Assessment questionnaire is to be completed for discharge from the Agency due to the patient’s death.
      3. A verbal physician’s order is also required to discharge due to patient expiration. This order is a formality to close the chart.

Transmission of OASIS DATA

All OASIS data is encoded and transmitted for each patient within 7 days of completing an OASIS Data set.  OASIS data must be encoded and transmitted electronically using software from CMS or software that conforms to CMS standard electronic.

All OASIS data is transmitted no later than the last day of the current month.

Record-keeping of the OASIS Data Set

      1. The original handwritten assessment for each time point completed must be filed in the patient’s record behind the skilled discipline completing the OASIS data set questionnaire.
      2. The computer copy will be filed in the patient’s record behind miscellaneous.
      3. All files are backed up daily.
      4. If the Agency is unable to transmit OASIS data to the state due to computer malfunction, a backup system is located in the Administrator’s home that may be used until the problem is resolved.
      5. If the transmission program is disabled, a list of all OASIS data is kept by the Agency and data is transmitted as soon as the system is operational.

Validation of OASIS Data

The Validation report is requested by the Agency from the CASPER system. A copy of the printed report is reviewed by the office manager. The office manager corrects any clerical errors and submits the report to the Director of Nursing for correction of any clinical and omission errors. The Director of Nursing reports any trends to the Quality Assessment Performance Improvement Committee for discussion and action, if indicated.

Outcomes and adverse event reports are also collected from CASPER, reviewed by the Director of Nursing, and reviewed by the Quality Assessment Performance Improvement Committee.

OASIS Corrections

      1. The agency will maintain policies and procedures that govern the correction of clinical records.
      2. The agency will allow specific staff may correct records in the event of staff turnover or staff schedules.
      3. For example, a clinical supervisor may be permitted to make corrections when the original clinician is no longer available due to staff turnover.
      4. When a comprehensive assessment is corrected, the agency will maintain the original assessment record as well as all subsequent corrected assessments in the patient’s clinical record for five years, or longer, by the clinical record requirements at 42 CFR 484.48.
      5. If maintained electronically, the agency must be capable of retrieving and reproducing a hard copy of these assessments upon request.
      6. It is acceptable to have multiple corrected assessments for an OASIS assessment, as long as the OASIS and the clinical record are documented in accordance with the requirements at 42 CFR 484.48, Clinical records.
      7. The agency will utilize the OASIS Correction Form located on the USB drive.