CHAPTER 3: ITEM-BY-ITEM GUIDE TO THE OASIS ASSESSMENT INSTRUMENT

Chapter 3 Chapter 3

Item-by-Item Guide to the OASIS Assessment Instrument CHAPTER 3: ITEM-BY-ITEM GUIDE TO THE OASIS ASSESSMENT INSTRUMENT

3.1 Overview

This chapter provides item-by-item coding instructions for HH assessing clinicians to complete each section of the OASIS-E instrument. The goal of this chapter is to provide HH staff with the rationale and guidance necessary to accurately complete each item of the OASIS Assessment. OASIS-E is a major revision to the OASIS instrument and guidance manual resulting in significant instrument redesign and manual reorganization. To align the items and guidance across the PAC settings, multiple new standardized items have been added to OASIS-E, new sections have been added or renamed, items have been reorganized within the sections, and the format for item specific guidance has changed. 3.2 OASIS-E Sections

OASIS-E includes the following sections:

Section Title

A Administrative Information

Section Title

H Bowel and Bladder

• Patient Tracking B Hearing, Speech, and Vision I Active Diagnoses C Cognitive Patterns J Health Conditions D Mood K Swallowing/Nutritional Status E Behavior M Skin Conditions

F Preferences for Customary Routine Activities N Medications

G Functional Status

GG Functional Status: Functional Abilities and Goals O Special Treatments, Procedures and Programs Q Participation in Assessment and Goal Setting

3.3 Using This Chapter

Item-specific guidance has been included for all new items introduced in OASIS-E and for those retained from OASIS-D. Each section begins with a brief introduction describing the items found in the section. The sources of information clinicians use to respond to items are now located in the first bullet under Response-Specific Instructions, and the OASIS-D Section “Data Sources/Resources” has been removed. Dash language has been added to each item indicating whether a Dash is an acceptable response or not. General formatting and organization changes have been made to improve clarity and remove redundancy. Throughout this chapter, the sections of OASIS-E are presented using a standard format for ease of review by HH staff. The layout and text color for headings varies from OASIS-D. Item-specific guidance includes additional headings to convey information, for example, Coding Instructions, Coding Tips and Examples where appropriate, the order of information for all items in each section of the OASIS-E is presented as follows:

OASIS-E Guidance Manual Effective 1/1/2023 Centers for Medicare & Medicaid Services Page 9

Chapter 3 Chapter 3

Item-by-Item Guide to the OASIS Assessment Instrument

• Item Display.Item-specific guidance begins with a screen shot, which displays the item from the

OASIS-E instrument. • Intent. States the reason(s) for including this item in the OASIS-E. • Time Point(s) Items Completed. Lists when the information for the data element is to be collected during the patient’s home health episode of care. • Item Rationale.Explains the purpose, meaning or importance of the item; the reason why the item is needed. • Response Specific Instructions.General instructions for how to complete the item, that apply to most, if not all, situations; how users are intended to collect information to complete the item. • Coding Instructions.Provides additional information to supplement the instructions found in the data element. • Coding Tips.Any special situations, outliers or uncommon scenarios; or any tips to clarify confusing or equivocal circumstances when coding each OASIS-E item. • Examples.Illustrates examples of appropriate coding for several of the OASIS-E sections/items

OASIS-E Guidance Manual Effective 1/1/2023 Centers for Medicare & Medicaid Services