Download QI - Briggs

RECERTIFICATION / FOLLOW-UP
ASSESSMENT
HHRG Case Mix Legend:
CSD = Clinical Severity Domain
INCLUDING OASIS ELEMENTS AND
CMS 485 INFORMATION
FSD = Functional Status Domain
SUD = Service Utilization Domain
Follow M00 numbers in sequence unless otherwise directed.
◆
DATE________/________/_______
QI = Quality Indicator
REASON FOR ASSESSMENT: ❑ Recertification ❑ Other Follow-up
TIME IN___________ TIME OUT___________
This Patient Tracking Information must be filled out at start of care and per organizational policy.
It is to be maintained as part of the clinical record.
(M0010)
__ __ __
(M0012)
__ __ __
(M0065) Medicaid Number: ❑ NA-No Medicaid
__ __ __ __ __ __ __ __ __ __ __ __ __ __
Agency Medicare Provider Number: (Locator #5)
__ __ __
Agency Medicaid Provider Number:
__ __ __ __ __ __ __ __ __ __ __ __
(M0066) Birth Date: (Locator #8) __ __ /__ __ /__ __ __ __
month
Branch Identification (M0014) Branch State: __ __
(M0016) Branch ID Number: __ __ __ __ __ __ __ __ __ __
Medical Record Number if different than M0020
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
(M0032) Resumption of Care Date:
❑ NA - Not Applicable
(M0040) Patient’s Name: (Locator #6)
__ __ __ __ __ __ __ __ __ __ __ __
(First)
.
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year
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__ __ /__ __ /__ __ __ __
month
day
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__
(MI)
year
__ __ __
(Suffix)
Patient Phone: __ __ __ - __ __ __ - __ __ __ __
Patient Address: (Locator #6)
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
w
(Street/Apt. No.)
__ __ __ __ __ __ __ __ __ __ __ __ __
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©S
(City)
(M0060) Patient Zip Code: (Locator #6) __ __ __ __ __ - __ __ __ __
(M0063) Medicare Number: ❑ NA - No Medicare
__ __ __ __ __ __ __ __ __ __ __ __ (including suffix)
___ ___/___ ___/___ ___ ___ ___
month
day
year
Address: (Street/Apt. No.)
__ __ __ __ __ __ __
City: (Locator #24)
__ __ __ __ __ __ __
State: (Locator #24)
__ __
(Last)
__
(MI)
__ __ __
(Suffix)
(Locator #24)
__ __ __ __ __ __ __ __ __ __ __ __ __ __
__ __ __ __ __ __
Zip Code: (Locator #24)
__ __ __ __ __ - __ __ __ __
3
4
3
0
0
(8
2
7
(First)
(MI)
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
(Last)
__ __ __
(Suffix)
Address: (Street/Apt. No.)
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
City: __ __ __ __ __ __ __ __ __ __ __ __ __
State: __ __ Zip Code: __ __ __ __ __ - __ __ __ __
CLINICAL RECORD ITEMS
(M0080) Discipline of Person Completing Assessment:
❑ 1-RN ❑ 2-PT ❑ 3-SLP/ST ❑ 4-OT
(M0090) Date Assessment Completed:
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
4
2
)
(M0064) Social Security Number: ❑ UK-Unknown or Not Available
__ __ __ - __ __ - __ __ __ __
❑ Skilled
❑ Skilled & Supervisory
(First)
Secondary Referring Physician I.D.#: __ __ __ __ __ __ __ __ __ __
Phone: __ __ __ - __ __ __ - __ __ __ __
Name: __ __ __ __ __ __ __ __ __ __ __ __
__
(M0050) Patient State of Residence: (Locator #6) __ __
Type of Visit:
E
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Name: (Locator #24) __ __ __ __ __ __ __ __ __ __ __ __
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__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
(Last)
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(M0072) Primary Referring Physician I.D.: ❑ UK-Unknown or
Not Available
__ __ __ __ __ __ __ __ __ __
Phone: (Locator #24) __ __ __ - __ __ __ - __ __ __ __
(M0030) Start of Care Date: (Locator #2) __ __ /__ __ /__ __ __ __
day
year
❑ 1-Male ❑ 2-Female
(M0069) Gender: (Locator #9)
(M0020) Patient ID Number: (Locator #4)
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
month
day
Patient’s HI Claim No.: (Locator #1)
❑ 1 - Same as M0063 ❑ 2 - Same as M0065
❑ 3 - Other __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
❑ Supervisory only
❑ Other ___________________
(M0100) This Assessment is Currently Being Completed for the
Following Reason:
❑ 4 - Recertification (follow-up) reassessment [Go to M0175]
❑ 5 - Other follow-up [Go to M0175]
Complete M0032 information
Certification Period: (Locator #3)
From ____/_____/________ To ____/____/________
PATIENT HISTORY
(M0175) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)
❑ 1 - Hospital If Blank, SUD +1
❑ 2 - Rehabilitation facility SUD +2
❑ 3 - Skilled nursing facility SUD +2
❑ 4 - Other nursing home
❑ 5 - Other (specify) _______________________________________________________________________________________________________________
❑ NA - Patient was not discharged from an inpatient facility
ID#
PATIENT NAME–Last, First, Middle Initial
Form 3492P © 2003 Briggs Medical Service Company (800) 247-2343 www.BriggsCorp.com. The Outcome and ASsessment Information Set (OASIS)
R107
is the intellectual property of the Center for Health Services and Policy Research, Denver, Colorado. It is used with permission.
Page 1 of 13
RECERTIFICATION/
FOLLOW-UP ASSESSMENT
Patient Name______________________________________________________________________________________________________ ID #________________________________________
PATIENT HISTORY (Cont’d.)
(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis and ICD-9-CM code at the level of highest specificity (no surgical codes)
for which the patient is receiving home care. Rate each condition using the following severity index. (Choose one value that represents the most severe
rating appropriate for each diagnosis.) E-codes (for M0240 only) or V-codes (for M0230 or M0240) may be used. ICD-9-CM sequencing requirements
must be followed if multiple coding is indicated for any diagnosis. If a V-code is reported in place of a case mix diagnosis, then M0245 Payment
Diagnosis should be completed. Case mix diagnosis is a primary or first secondary diagnosis that determines the Medicare PPS case mix group.
0 - Asymptomatic, no treatment needed at this time
CSD +11
M0230/M0240 Orthopedic Dx
1 - Symptoms well controlled with current therapy
CSD +17
Diabetes Dx
2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring
Neurological Dx CSD +20
3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring
4 - Symptoms poorly controlled, history of rehospitalizations
(M0230) Primary Diagnosis
ICD-9-CM (Locator #11)
Severity Rating
a. ____________________________________________
( ____ ____ ____•____ ____ )
❑0 ❑1 ❑2 ❑3 ❑4
(M0240) Other Diagnosis
ICD-9-CM (Locator #13)
Severity Rating
Date _____/_____/_____ O/E
b. ____________________________________________ ( ____ ____ ____ ____•____ ____ )
❑0 ❑1 ❑2 ❑3 ❑4
Date _____/_____/_____ O/E
c. ____________________________________________ ( ____ ____ ____ ____•____ ____ )
❑0 ❑1 ❑2 ❑3 ❑4
Date _____/_____/_____ O/E
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d. ____________________________________________ ( ____ ____ ____ ____•____ ____ )
❑0 ❑1 ❑2 ❑3 ❑4
Date _____/_____/_____ O/E
e. ____________________________________________ ( ____ ____ ____ ____•____ ____ )
❑0 ❑1 ❑2 ❑3 ❑4
Date _____/_____/_____ O/E
f. ____________________________________________ ( ____ ____ ____ ____•____ ____ )
❑0 ❑1 ❑2 ❑3 ❑4
Date _____/_____/_____ O/E
Surgical Procedure
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ICD-9-CM (Locator #12)
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______________________________________________
( ____ ____ ____•____ ____ )
______________________________________________
( ____ ____ ____•____ ____ )
Date _____/_____/_____ O/E
Date _____/_____/_____ O/E
(M0245) Payment Diagnosis (optional): If a V-code was reported in M0230 in place of a case mix diagnosis, list the primary diagnosis and
ICD-9-CM code, determined in accordance with OASIS requirements in effect before October 1, 2003 – no V-codes, E-codes, or
surgical codes allowed. ICD-9-CM sequencing requirements must be followed. Complete both lines (a) and (b) if the case mix
diagnosis is a manifestation code or in other situations where multiple coding is indicated for the primary diagnosis; otherwise,
complete line (a) only.
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(M0245) Primary Diagnosis
2
7
3
4
3
a.__________________________________________________________________________________________________
(M0245) First Secondary Diagnosis
24
( ____ ____ ____•____ ____ )
b.__________________________________________________________________________________________________
)
0
0
(M0250) Therapies the patient receives at home: (Mark all that apply.)
❑ 1 - Intravenous or infusion therapy (excludes TPN) CSD+14
❑ 2 - Parenteral nutrition (TPN or lipids) CSD +20
❑ 3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any
other artificial entry into the alimentary canal) CSD +24
❑ 4 - None of the above
(8
PROGNOSIS (Locator #20)
❑ 1-Poor ❑ 2-Guarded
ICD-9-CM
( ____ ____ ____•____ ____ )
❑ 3-Fair
SENSORY STATUS
ICD-9-CM
❑ 4-Good
❑ 5-Excellent
PAIN
(M0390) Vision with corrective lenses if the patient usually wears them:
Intensity: (using scales below)
❑ 0 - Normal vision: sees adequately in most situations; can see medication labels, newsprint.
Wong-Baker FACES Pain Rating Scale
❑ 1 - Partially impaired: cannot see medication labels or newsprint, but
can see obstacles in path, and the surrounding layout; can count
fingers at arm’s length. CSD +6
❑ 2 - Severely impaired: cannot locate objects without hearing or touching them or patient nonresponsive. CSD +6
NO HURT
HURTS
LITTLE BIT
HURTS
LITTLE MORE
HURTS
EVEN MORE
0
2
4
6
No
Pain
Moderate
Pain
HURTS
WHOLE LOT
8
HURTS
WORSE
10
Worst
Possible Pain
**From
Wong D.L., Hockenberry-Eaton M., Wilson D., Winkelstein M.L., Schwartz P.:
Wong’s Essentials of Pediatric Nursing, ed. 6, St. Louis, 2001, p. 1301. Copyrighted by
Mosby, Inc. Reprinted by permission.
Collected using: ❑ FACES Scale ❑ 0-10 Scale (subjective reporting)
Form 3492P © 2003 Briggs Medical Service Company (800) 247-2343 www.BriggsCorp.com. The Outcome and ASsessment Information Set (OASIS)
is the intellectual property of the Center for Health Services and Policy Research, Denver, Colorado. It is used with permission.
Page 2 of 13
RECERTIFICATION/
FOLLOW-UP ASSESSMENT
Patient Name______________________________________________________________________________________________________ ID #________________________________________
PAIN (Cont’d.)
◆
❑ No Problem
QI (M0420) Frequency of Pain interfering with patient’s activity or movement:
❑ 0 - Patient has no pain or pain does not interfere with activity or
Is patient experiencing pain? ❑ Yes ❑ No
movement
❑ Unable to communicate
❑ 1 - Less often than daily
Non-verbals demonstrated: ❑ Diaphoresis ❑ Grimacing
❑ 2 - Daily, but not constantly CSD + 5
❑ Moaning/Crying ❑ Guarding ❑ Irritability ❑ Anger
❑ 3 - All of the time CSD + 5
❑ Tense ❑ Restlessness ❑ Change in vital signs
❑ Other:_______________________________________________
Frequency: ❑ Occasionally ❑ Continuous ❑ Intermittent
❑ Self-assessment ❑ Implications: __________________________
❑ Other:________________________________________________
_____________________________________________________
What
makes pain worse? ❑ Movement ❑ Ambulation ❑ Immobility
_____________________________________________________
❑ Other:________________________________________________
Pain Assessment
Site 1
Site 2
Site 3
What makes pain better? ❑ Heat/Ice ❑ Massage ❑ Repositioning
Location
❑ Rest/Relaxation ❑ Medication ❑ Diversion
Onset
❑ Other: _______________________________________________
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How often is breakthrough medication needed?
Present level (0-10)
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❑ More than 3 times/day
Best pain gets (0-10)
❑ Current pain control medications adequate
Pain description
(aching, radiating,
throbbing, etc.)
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❑ Other: _______________________________________________
Implications Care Plan: ❑ Yes ❑ No
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INTEGUMENTARY STATUS
(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes “OSTOMIES.”
❑ 0 - No [If No, go to M0490 ]
❑ 1 - Yes If M0230 is Burn/Trauma DG, CSD+21
WOUND / LESION
(specify)
Location
#1
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#2
Type: diabetic ulcer
pressure ulcer
venous stasis ulcer
arterial ulcer
traumatic wound
burn wound
surgical wound
other (specify)
A
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#3
0
0
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Size (cm) (LxWxD)
Stage
(pressure ulcers only)
Tunneling /
Undermining
Odor
E
L
❑ Never ❑ Less than daily ❑ 2-3 times/day
Worst pain gets (0-10)
4
2
)
2
7
#4
#5
3
4
3
Surrounding Skin
Edema
Stoma
Appearance of
the Wound Bed
Drainage /Amount
❑
❑
❑
❑
None
Small
Moderate
Large
❑
❑
❑
❑
None
Small
Moderate
Large
❑
❑
❑
❑
None
Small
Moderate
Large
❑
❑
❑
❑
None
Small
Moderate
Large
❑
❑
❑
❑
None
Small
Moderate
Large
Color
❑
❑
❑
❑
Clear
Tan
Serosanguineous
Other
❑
❑
❑
❑
Clear
Tan
Serosanguineous
Other
❑
❑
❑
❑
Clear
Tan
Serosanguineous
Other
❑
❑
❑
❑
Clear
Tan
Serosanguineous
Other
❑
❑
❑
❑
Clear
Tan
Serosanguineous
Other
Consistency
❑ Thin
❑ Thick
❑ Thin
❑ Thick
❑ Thin
❑ Thick
❑ Thin
❑ Thick
Form 3492P © 2003 Briggs Medical Service Company (800) 247-2343 www.BriggsCorp.com. The Outcome and ASsessment Information Set (OASIS)
is the intellectual property of the Center for Health Services and Policy Research, Denver, Colorado. It is used with permission.
Page 3 of 13
❑ Thin
❑ Thick
RECERTIFICATION/
FOLLOW-UP ASSESSMENT
Patient Name______________________________________________________________________________________________________ ID #________________________________________
INTEGUMENTARY STATUS (Cont’d.)
(M0450) Current Number of Pressure Ulcers at Each Stage: (Circle one response for each stage.)
Pressure Ulcer Stages
NOTE: Any combination of 2 or more
stage 3 or 4 pressure ulcers = CSD+17
Number of Pressure Ulcers
0
1
2
3
4 or
more
b) Stage 2: Partial thickness skin loss involving epidermis and/or dermis. The ulcer is
superficial and presents clinically as an abrasion, blister, or shallow crater.
0
1
2
3
4 or
more
c) Stage 3: Full-thickness skin loss involving damage or necrosis of subcutaneous tissue
which may extend down to, but not through, underlying fascia. The ulcer presents
clinically as a deep crater with or without undermining of adjacent tissue.
0
1
2
3
4 or more
d) Stage 4: Full-thickness skin loss with extensive destruction, tissue necrosis, or damage
to muscle, bone, or supporting structures (e.g., tendon, joint capsule, etc.)
0
1
CSD + 17
a) Stage 1: Nonblanchable erythema of intact skin; the heralding of skin ulceration. In
darker-pigmented skin, warmth, edema, hardness, or discolored skin may be indicators.
CSD + 17 CSD + 17 CSD + 17
4 or more
2
3
CSD + 17 CSD + 17 CSD + 17
e) In addition to the above, is there at least one pressure ulcer that cannot be observed due to the presence of eschar or a nonremovable
dressing, including casts?
❑ 0 - No
❑ 1 - Yes
(Skip this item if patient has no pressure ulcers.)
(M0460) Stage of Most Problematic (Observable) Pressure Ulcer:
CSD + 36
❑ 1 - Stage 1 CSD +15
❑ 4 - Stage 4
❑ 2 - Stage 2 CSD +15
❑ NA - No observable pressure ulcer
❑ 3 - Stage 3 CSD + 36
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DEFINITION: (M0450, M0460) WOCN Guidance
Pressure Ulcer Stages: Stage 1 through Stage 4 the same as listed
in M0450
Non-observable: Wound is unable to be visualized due to an orthopedic
device, dressing, etc. A pressure ulcer cannot be accurately staged until
the deepest viable tissue layer is visible; this means that wounds
covered with eschar and/or slough cannot be staged, and should be
documented as non-observable.
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DEFINITION: (M0488) WOCN Guidance
Description/classification of wounds healing by primary intention (i.e.,
approximated incisions)
• Fully granulating/healing: Incision well-approximated with complete
epithelialization of incision; no signs or symptoms of infection.
3
4
3
• Early/partial granulation: Incision well-approximated but not completely
epithelialized; no signs or symptoms of infection.
• Non-healing: Incisional separation OR incisional necrosis OR signs or
symptoms of infection.
2
7
Description/classification of wounds healing by secondary intention (i.e.,
healing of dehisced wound by granulation, contraction and
epithelialization)
4
2
)
• Fully granulating: Wound bed filled with granulation tissue to the level
of the surrounding skin or new epithelium; no dead space, no
avascular tissue (eschar and/or slough); no signs or symptoms of
infection; wound edges are open.
(Skip this item if patient does not have a stasis ulcer).
(M0476) Status of Most Problematic (Observable) Stasis Ulcer:
❑ 1 - Fully granulating
❑ 2 - Early/partial granulation CSD + 14
❑ 3 - Not healing CSD + 22
❑ NA - No observable stasis ulcer
DEFINITION: (M0476) WOCN Guidance
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DEFINITION: (M0450, M0460) WOCN Guidance
Pressure Ulcer: Any lesion caused by unrelieved pressure resulting in
damage of underlying tissue. Pressure ulcers are usually located over
bony prominences and are staged to classify the degree of tissue
damage observed.
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((Skip this item if patient has no surgical wounds).
(M0488) Status of Most Problematic (Observable) Surgical Wound:
❑ 1 - Fully granulating
❑ 2 - Early/partial granulation CSD + 7
❑ 3 - Not healing CSD + 15
❑ NA - No observable surgical wound
0
0
(8
• Early/Partial Granulation: Greater than or equal to 25% of the wound
bed is covered with granulation tissue; there is minimal avascular
tissue (eschar and/or slough) (i.e., less than 25% of the wound bed is
covered with avascular tissue); may have dead space; no signs or
symptoms of infection; wound edges open.
1. Fully Granulating: Wound bed filled with granulation tissue to the level
of the surrounding skin or new epithelium; no dead space, no
avascular tissue (eschar and/or slough); no signs or symptoms of
infection; wound edges are open.
2. Early/Partial Granulation: Greater than or equal to 25% of the wound
bed is covered with granulation tissue; there is minimal avascular
tissue (eschar and/or slough) (i.e., less than 25% of the wound bed is
covered with avascular tissue); may have dead space; no signs or
symptoms of infection; wound edges open.
• Non-healing: Wound with greater than or equal to 25% avascular tissue
(eschar and/or slough) OR signs/symptoms of infection OR clean but
non-granulating wound bed OR closed /hyperkeratotic wound edges
OR persistent failure to improve despite comprehensive appropriate
wound management.
3. Non-healing: Wound with greater than or equal to 25% avascular tissue
(eschar and/or slough) OR signs/symptoms of infection OR clean but
non-granulating wound bed OR closed/hyperkeratotic wound edges
OR persistent failure to improve despite appropriate comprehensive
wound management. Note: A new Stage I pressure ulcer is reported
on OASIS as not healing.
Form 3492P © 2003 Briggs Medical Service Company (800) 247-2343 www.BriggsCorp.com. The Outcome and ASsessment Information Set (OASIS)
is the intellectual property of the Center for Health Services and Policy Research, Denver, Colorado. It is used with permission.
Page 4 of 13
RECERTIFICATION/
FOLLOW-UP ASSESSMENT
Patient Name______________________________________________________________________________________________________ ID #________________________________________
INTEGUMENTARY STATUS (Cont’d.)
Wound care done: ❑ Yes ❑ No
❑ Soiled dressing removed
Location(s) if patient has more than one wound site: ____________________________________________________
By: ❑ Patient ❑ Family/caregiver ❑ RN / PT
❑ Wound cleaned with (specify):______________________________________________________________________________________________________
❑ Wound irrigated with (specify): _____________________________________________________________________________________________________
❑ Wound packed with (specify): ______________________________________________________________________________________________________
❑ Wound dressing applied (specify): __________________________________________________________________________________________________
❑ Patient tolerated procedure well
❑ Other (specify): ___________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
Satisfactory return demo: ❑ Yes ❑ No
Education: ❑ Yes
SYSTEMS REVIEW
CARDIOPULMONARY (Cont’d.)
Weight:__________ ❑ reported ❑ actual
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❑ Hypoglycemia: Sweats / Polyphagia / Weak / Faint / Stupor
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Who manages? ❑ Self ❑ RN ❑ Caregiver/family
❑ Blood sugar ranges___________________ ❑ Patient /Caregiver report
Monitored by: ❑ Self ❑ RN ❑ Caregiver/Family
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❑ Cough: Dry / Acute / Chronic
❑ Productive: Thick /Thin
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❑ Other:____________________________________________________
❑ Unequal pupils: R /L
Color _________________________________________________
Amount_______________________________________________
❑ Unable to cough up secretions
Hand grips: Equal / Unequal (specify) ________________________________
❑ Dyspnea: ❑ Rest ❑ Exertion ❑ Ambulation_______feet
Strong / Weak (specify) _________________________________
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CARDIOPULMONARY
❑ During ADL’s
❑ Orthopnea
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Pulse:
❑ Chest Pain: ❑ Anginal ❑ Postural ❑ Localized ❑ Substernal
❑ Oral
❑ Rectal
❑ Axillary
❑ Tympanic
❑ Apical_______ ❑ Brachial_______
❑ Radial_______ ❑ Carotid_______
❑ Regular / Irregular
❑ Rest ❑ Activity
Heart Sounds: ❑ Regular / Irregular ❑ Murmur
Associated with: ❑ Shortness of breath ❑ Activity ❑ Sweats
4
2
)
Frequency/duration: _____________________________________
0
0
(8
❑ Palpitations ❑ Fatigue
❑ Anterior: ❑ Right
❑ Posterior: ❑ Right
❑ Left
❑ Left
❑ Upper
❑ Upper
❑ Lower
❑ Lower
❑ Accessory muscles used ❑ O2 @_____ LPM per ________
O2 saturation _____%
❑ Other: ________________________________________________
_____________________________________________________
❑ Dependent: ____________________________________
❑ Pitting +1/+2/+3/+4
❑ Non-pitting
Site: ____________________________________________________
❑ Cramps ❑ Claudication
❑ Capillary refill less than 3 sec / greater than 3 sec
❑ Other ___________________________________________________
❑ Regular/Irregular ❑ Cheynes Stokes
❑ Death rattle ❑ Apnea periods ____sec.
Breath Sounds: ❑ Clear ❑ Crackles /Rales ❑ Wheezes / Rhonchi
❑ Diminished ❑ Absent
_____________________________________
❑ Edema: ❑ Pedal Right /Left ❑ Sacral
❑ Pacemaker: Date _______________________________________
Type_______________________________________
Respirations:__________
2
7
❑ Radiating ❑ Dull ❑ Ache ❑ Sharp ❑ Vise-like
❑ Sitting/lying R__________ L__________
❑ Standing
R__________ L__________
Temperature:__________
3
4
3
❑ Other: ________________________________________________
❑ No Problem
This section completed in accordance with organizational policy.
(Circle all applicable items)
Blood Pressure:
E
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Does this patient have a trach? ❑ Yes ❑ No
❑ Hyperglycemia: Glycosuria / Polyuria / Polydipsia
❑ PERRLA
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Breath Sounds (cont’d.):
________________________________________________________
________________________________________________________
When is the patient dyspneic or noticeably Short of Breath?
◆❑(M0490)
0 - Never, patient is not short of breath
QI
❑ 1 - When walking more than 20 feet, climbing stairs
❑ 2 - With moderate exertion (e.g., while dressing, using commode
or bedpan, walking distances less than 20 feet) CSD + 5
❑ 3 - With minimal exertion (e.g., while eating, talking, or performing
other ADLs) or with agitation CSD + 5
❑ 4 - At rest (during day or night) CSD + 5
❑ Observed ❑ Reported
Form 3492P © 2003 Briggs Medical Service Company (800) 247-2343 www.BriggsCorp.com. The Outcome and ASsessment Information Set (OASIS)
is the intellectual property of the Center for Health Services and Policy Research, Denver, Colorado. It is used with permission.
Page 5 of 13
RECERTIFICATION/
FOLLOW-UP ASSESSMENT
Patient Name______________________________________________________________________________________________________ ID #________________________________________
NUTRITIONAL STATUS
ELIMINATION (Cont’d.)
❑ No Problem
Bowel sounds ❑ active / absent / hypo /hyperactive x ______quadrants
(Locator #16)
Nutritional requirements (diet) ❑ Regular ❑ NAS ❑ NPO
❑ No Concentrated Sweets
Special diet (list) _________________________________________________
❑ Increase fluids____________amt. ❑ Restrict fluids____________amt.
❑ Other __________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
Appetite: ❑ Good ❑ Fair ❑ Poor ❑ Anorexic
(Skip this item if patient has no
urinary incontinence or does have a urinary catheter)
Intake Adequate: ❑ Yes ❑ No
Hydration Adequate: ❑ Yes ❑ No
❑ Nausea/Vomiting
❑ Other __________________________________________________________
❑ Change in nutritional risk ❑ No ❑ Yes (explain)___________________
_______________________________________________________________
ALLERGIES
Allergies: (Locator #17) ❑ None known
❑ Penicillin
❑ Sulfa
❑ Milk products
❑ Pollen
❑ Aspirin
❑ Eggs
❑ Insect bites
❑ Other ________________________________________________________
(M0540) Bowel Incontinence Frequency:
❑ 0 - Very rarely or never has bowel incontinence
❑ 1 - Less than once weekly
❑ 2 - One to three times weekly CSD + 9
❑ 3 - Four to six times weekly CSD + 9
❑ 4 - On a daily basis CSD + 9
❑ 5 - More often than once daily CSD + 9
C
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______________________________________________________________
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______________________________________________________________
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(M0530) When does Urinary Incontinence occur?
❑ 0 - Timed-voiding defers incontinence
❑ 1 - During the night only CSD + 6
❑ 2 - During the day and night CSD + 6
GENITOURINARY
❑ No Problem
(Circle all applicable items)
w
❑ Urgency/frequency ❑ Retention ❑ Burning/pain
❑ Hesitancy ❑ Nocturia ❑ Hematuria ❑ Oliguria/anuria
(M0550) Ostomy for Bowel Elimination: Does this patient have an
ostomy for bowel elimination that (within the last 14 days): a) was
related to an inpatient facility stay, or b) necessitated a change in
medical or treatment regimen?
❑ 0 - Patient does not have an ostomy for bowel elimination.
A
©S
_____________________________________________________
❑ 2 - The ostomy was related to an inpatient stay or did necessitate
change in medical or treatment regimen. CSD + 10
Urinary Catheter: Type (specify) ______________________________
❑ Foley inserted (date) _______________ with ___________ French
Amount______ml Frequency_____________________
❑ Patient tolerated procedure well
ELIMINATION
❑ No Problem
❑ Flatulence ❑ Constipation/impaction ❑ Diarrhea
❑ Rectal bleeding ❑ Hemorrhoids ❑ Last BM_________________
❑ Incontinence (detail if applicable)_____________________________
_______________________________________________________
_______________________________________________________
4
2
)
(M0610) Behaviors Demonstrated at Least Once a Week
(Reported or Observed): (Mark all that apply.)
❑ 1 - Memory deficit: failure to recognize familiar persons/places,
inability to recall events of past 24 hours, significant memory loss
so that supervision is required. CSD + 3
0
0
(8
Irrigation solution: Type (specify):_____________________________
2
7
NEURO / EMOTIONAL / BEHAVIOR STATUS
❑ Diapers/other: _________________________________________
Inflated balloon with ______ml ❑ without difficulty
3
4
3
❑ 1 - Patient’s ostomy was not related to an inpatient stay and did not
necessitate change in medical or treatment regimen. CSD + 10
❑ Incontinence (detail if applicable)___________________________
Date last changed______________________
E
L
❑ NA - Patient has ostomy for bowel elimination
______________________________________________________________
❑ 2 - Impaired decision-making: failure to perform usual ADLs or IADLs,
inability to appropriately stop activities, jeopardizes safety through
actions. CSD + 3
❑ 3 - Verbal disruption: yelling, threatening, excessive profanity, sexual
references, etc. CSD + 3
❑ 4 - Physical aggression: aggressive or combative to self and others
(e.g., hits self, throws objects, punches, dangerous maneuvers
with wheelchair or other objects). CSD + 3
❑ 5 - Disruptive, infantile, or socially inappropriate behavior (excludes
verbal actions). CSD + 3
❑ 6 - Delusional, hallucinatory, or paranoid behavior. CSD + 3
❑ 7 - None of the above behaviors demonstrated.
MENTAL STATUS
❑ Frequency of stools:______________________
Bowel regime/program: ____________________________________
_______________________________________________________
❑ Ileostomy/colostomy site (describe skin around stoma): ___________
_______________________________________________________
(Locator #19)
❑ 1 - Oriented
❑ 2 - Comatose
❑ 3 - Forgetful
❑ 4 - Depressed
❑ 5 - Disoriented
❑ 6 - Lethargic
❑ 7 - Agitated
❑ 8 - Other __________________________________
__________________________________
Form 3492P © 2003 Briggs Medical Service Company (800) 247-2343 www.BriggsCorp.com. The Outcome and ASsessment Information Set (OASIS)
is the intellectual property of the Center for Health Services and Policy Research, Denver, Colorado. It is used with permission.
Page 6 of 13
RECERTIFICATION/
FOLLOW-UP ASSESSMENT
Patient Name______________________________________________________________________________________________________ ID #________________________________________
ADL / IADLs
For M0650 – M0700, record what the patient currently is able to do.
M0650) Ability to Dress Upper Body (with or without dressing aids)
(M0680) Toileting: Ability to get to and from the toilet or bedside
◆including
undergarments, pullovers, front-opening shirts and blouses, ◆
commode.
QI
QI
managing zippers, buttons, and snaps:
❑ 0 - Able to get clothes out of closets and drawers, put them on
and remove them from the upper body without assistance.
❑ 1 - Able to dress upper body without assistance if clothing is laid out
or handed to the patient. FSD + 4
❑ 2 - Someone must help the patient put on upper body clothing.
FSD + 4
❑ 3 - Patient depends entirely upon another person to dress the upper
body. FSD + 4
❑ 0 - Able to get to and from the toilet independently with or without a
device.
❑ 1 - When reminded, assisted, or supervised by another person, able
to get to and from the toilet.
❑ 2 - Unable to get to and from the toilet but is able to use a bedside
commode (with or without assistance). FSD + 3
❑ 3 - Unable to get to and from the toilet or bedside commode but
is able to use a bedpan/urinal independently. FSD + 3
❑ 4 - Is totally dependent in toileting. FSD + 3
(M0690) Transferring: Ability to move from bed to chair, on and off
◆toilet
or commode, into and out of tub or shower, and ability to turn
QI
(M0660) Ability to Dress Lower Body (with or without dressing aids)
including undergarments, slacks, socks or nylons, shoes:
❑ 0 - Able to obtain, put on, and remove clothing and shoes without
assistance.
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❑ 1 - Able to dress lower body without assistance if clothing and
shoes are laid out or handed to the patient. FSD + 4
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❑ 2 - Someone must help the patient put on undergarments, slacks,
socks or nylons, and shoes. FSD + 4
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❑ 3 - Patient depends entirely upon another person to dress lower
body. FSD + 4
◆
(M0670) Bathing: Ability to wash entire body. Excludes grooming
(washing face and hands only).
QI
❑ 1 - With the use of devices, is able to bathe self in shower or tub
independently.
❑ 2 - Able to bathe in shower or tub with the assistance of another
person: FSD + 8
(a) for intermittent supervision or encouragement or reminders,
OR
(b) to get in and out of the shower or tub, OR
(c) for washing difficult to reach areas.
A
©S
00
❑ 4 - Unable to use the shower or tub and is bathed in bed or bedside
chair. FSD + 8
(8
a variety of surfaces.
❑ 5 - Unable to effectively participate in bathing and is totally bathed
by another person. FSD + 8
2
7
❑ 1 - Requires use of a device (e.g., cane, walker) to walk alone or
requires human supervision or assistance to negotiate stairs or
steps or uneven surfaces. FSD + 6
❑ 2 - Able to walk only with the supervision or assistance of another
person at all times. FSD + 6
❑ 3 - Chairfast, unable to ambulate but is able to wheel self independently. FSD + 9
❑ 4 - Chairfast, unable to ambulate and is unable to wheel self.
FSD + 9
❑ 5 - Bedfast, unable to ambulate or be up in a chair. FSD + 9
Indications for Aide Services Offered: ❑ Yes ❑ No ❑ Refused
Orders obtained: ❑ Yes ❑ No
FUNCTIONAL LIMITATIONS
ACTIVITIES PERMITTED
(Locator #18A)
❑ 1-Amputation
❑ 2-Bowel/Bladder
(Incontinence)
❑ 3-Contracture
❑ 4-Hearing
❑ 5-Paralysis
❑ 6-Endurance
3
4
3
❑ 0 - Able to independently walk on even and uneven surfaces and
climb stairs with or without railings (i.e., needs no human
assistance or assistive device).
4
2
)
❑ 3 - Participates in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or
supervision. FSD + 8
E
L
(M0700) Ambulation/Locomotion: Ability to SAFELY walk, once in a
◆standing
position, or use a wheelchair, once in a seated position, on
QI
❑ 0 - Able to bathe self in shower or tub independently.
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and position self in bed if patient is bedfast.
❑ 0 - Able to independently transfer.
❑ 1 - Transfers with minimal human assistance or with use of an assistive device. FSD + 3
❑ 2 - Unable to transfer self but is able to bear weight and pivot during
the transfer process. FSD + 6
❑ 3 - Unable to transfer self and is unable to bear weight or pivot when
transferred by another person. FSD + 6
❑ 4 - Bedfast, unable to transfer but is able to turn and position self in
bed. FSD + 6
❑ 5 - Bedfast, unable to transfer and is unable to turn and position self.
FSD + 6
(Locator #18B)
❑ 7-Ambulation
❑ 8-Speech
❑ 9-Legally blind
❑ A-Dyspnea with minimal exertion
❑ B-Other (specify)___________________________
__________________________________________
__________________________________________
❑ 1-Complete bedrest
❑ 2-Bedrest/BRP
❑ 3-Up as tolerated
❑ 4-Transfer bed/chair
❑ 5-Exercises prescribed
❑ 6-Partial weight bearing
❑ 7-Independent in home
❑
❑
❑
❑
❑
❑
8-Crutches
9-Cane
A-Wheelchair
B-Walker
C-No restrictions
D-Other (specify) ___________________
________________________________
THERAPY
(M0825) Therapy Need: Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need
for therapy (physical, occupational, or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?
❑ 0 - No
❑ 1 - Yes [10 or more therapy visits] SUD +4
❑ NA - Not applicable
Form 3492P © 2003 Briggs Medical Service Company (800) 247-2343 www.BriggsCorp.com. The Outcome and ASsessment Information Set (OASIS)
is the intellectual property of the Center for Health Services and Policy Research, Denver, Colorado. It is used with permission.
Page 7 of 13
RECERTIFICATION/
FOLLOW-UP ASSESSMENT
Patient Name______________________________________________________________________________________________________ ID #________________________________________
FALL RISK REASSESSMENT
ENTERAL FEEDINGS - ACCESS DEVICE
❑ N/A ❑ No Problem
1. Any falls reported since last OASIS assessment?
❑ No ❑ Yes (describe) _____________________________________
❑ Nasogastric ❑ Gastrostomy ❑ Jejunostomy
________________________________________________________
❑ Other (specify)__________________________________________________
________________________________________________________
Pump: (type/specify) ______________________________________________
________________________________________________________
Feedings: ❑ Bolus ❑ Continuous
Flush Protocol: (amt./specify) _______________________________________
2. Have fall risk factors changed since prior assessment?
❑ No ❑ Yes (describe) _____________________________________
__________________________________________________________________
________________________________________________________
__________________________________________________________________
________________________________________________________
Performed by: ❑ Self ❑ RN ❑ Caregiver ❑ Other _________________
________________________________________________________
Dressing /Site care: (specify) ________________________________________
__________________________________________________________________
3. Complete the reassessment and score it when appropriate and
according to organization guidelines.
__________________________________________________________________
Interventions /Instructions / Comments________________________________
Assess each factor and circle the score when “yes”, then total the points.
Patient Factors
Score
History of falls (any in the past 3 months?)
15
Sensory deficit (vision and /or hearing)
5
Age (over 65)
5
Confusion
Impaired judgment
Decreased level of cooperation
g
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B
Increased anxiety / emotional liability
Unable to ambulate independently (needs to use ambulatory aide,
chairboard, etc.)
Gait / balance / coordination problems
Incontinence / urgency
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.
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Postural hypotension with dizziness
Alcohol use
A
©S
Environmental Factors
Lack of home modifications (bathroom, kitchen, stairs entries, etc.)
Implement fall precautions for a total score of 15 or greater.
❑ PICC: (specify, size, brand)__________________________________
P
M
5
5
❑ 7 - Elevate head of bed
________________________________________________________
❑ Central
5
❑ Midline/Midclavicular
❑ Single lumen ❑ Double lumen ❑ Triple lumen
5
Date of placement_________________________________________
5
❑ X-ray verification: ❑ Yes ❑ No
3
4
3
❑ Mid arm circumference _______________ in/cm
❑ External catheter length _______________ in/cm
2
7
❑ Hickman ❑ Broviac ❑ Groshong ❑ Jugular ❑ Subclavian
5
❑ Single lumen ❑ Double lumen ❑ Triple lumen
4
2
)
Date of placement_________________________________________
5
❑ Epidural catheter ❑ Tunneled ❑ Port
5
5
00
4. Organizational guidelines:
a. Educate on fall prevention strategies specific to areas of risk
b. Refer to Physical Therapy and/or Occupational Therapy
c. Monitor areas of risk to reduce falls
d. Reassess patient
Safety Measures: (Locator #15)
❑ 1 - Bleeding precautions
❑ 2 - O2 precautions
❑ 3 - Seizure precautions
❑ 4 - Fall precautions
❑ 5 - Aspiration precautions
❑ 6 - Siderails up
❑ N/A
❑ Peripheral: (specify) ________________________________________
(8
Total points:
INFUSION
5
5
Home safety issues (lighting, pathway, cord, tubing, floor coverings,
stairs, etc.)
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5
5
Medications affecting blood pressure or level of consciousness
(consider antihistamines, antihypertensives, antiseizure,
benzodiazepines, cathartics, diuretics, hypoglycemics, narcotics,
psychotropics, sedatives / hypnotics)
E
L
__________________________________________________________________
C
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Cardiovascular / respiratory disease affecting perfusion and/or
oxygenation
m
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__________________________________________________________________
Date of placement_________________________________________
❑ Implanted VAD ❑ Venous ❑ Arterial ❑ Peritoneal
Date of placement_________________________________________
❑ Intrathecal ❑ Port ❑ Reservoir
Date of placement_________________________________________
❑ Medication(s) administered:
(name of drug) ____________________________________________
Dose___________________ Route ___________________________
Frequency___________________Duration of therapy_____________
❑ Medication(s) administered:
❑
❑
❑
❑
❑
❑
8
9
10
11
12
13
-
24 hr. supervision
Clear pathways
Lock w/c with transfers
Infection control measures
Walker/cane
Other ____________________
_________________________
_________________________
(name of drug) ____________________________________________
Dose___________________ Route ___________________________
Frequency___________________Duration of therapy_____________
❑ Medication(s) administered:
(name of drug) ____________________________________________
Dose___________________ Route ___________________________
Frequency___________________Duration of therapy_____________
Form 3492P © 2003 Briggs Medical Service Company (800) 247-2343 www.BriggsCorp.com. The Outcome and ASsessment Information Set (OASIS)
is the intellectual property of the Center for Health Services and Policy Research, Denver, Colorado. It is used with permission.
Page 8 of 13
RECERTIFICATION/
FOLLOW-UP ASSESSMENT
Patient Name______________________________________________________________________________________________________ ID #________________________________________
INFUSION (Cont’d.)
❑ Pump: (type, specify) ______________________________________
Interventions / Instructions /Comments ________________________________
_______________________________________________________
__________________________________________________________________
Administered by: ❑ Self ❑ Caregiver ❑ RN
__________________________________________________________________
❑ Other _________________________________________________
__________________________________________________________________
❑ Dressing change: ❑ Sterile ❑ Clean
__________________________________________________________________
Performed by: ❑ Self ❑ RN ❑ Caregiver ❑ Other _________________
__________________________________________________________________
Frequency (specify) ________________________________________________
__________________________________________________________________
Injection cap change (specify frequency)_____________________________
__________________________________________________________________
Labs drawn _______________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
SKILLED INTERVENTIONS / INSTRUCTIONS DONE THIS VISIT
(Mark all applicable with an “X”. Circle appropriate item(s) separated by “/”.)
m
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NURSING INTERVENTIONS/INSTRUCTIONS
Skilled observation & assessment
Teach/Admin. IVs /Clysis
Foley care
Teach ostomy/Ileo. conduit care
Wound care/dressing
Teach/Admin. tube feedings
Decubitus care
Teach/Admin. care of trach.
Venipuncture
Change NG/G tube
Diabetic observation
Teach diabetic care
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Teach infant/child care
Pain Management
Teach care - terminally ill
Physiology/Disease process teaching
Other:
IM injection
Diet teaching
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Safety factors
Observe S/S infection
Prep./Admin. insulin
Post-partum assessment
Observe /Teach medication (N or C)
effects /side effects
Psych. intervention
Admin. of vitamin B12
Evaluation
C
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Prenatal assessment
Fall Safety Teaching
PHYSICAL THERAPY INTERVENTIONS/INSTRUCTIONS
Fill Out Per Organizational Policy
Balance training/activities
A
©S
Establish upgrade home exercise program
Pulmonary Physical Therapy
❑ Copy given to patient/client
Ultrasound
❑ Copy attached to chart
Electrotherapy
Patient/Family education
Prosthetic training
Therapeutic exercise
TENS
Transfer training
Functional mobility training
Gait training
Teach bed mobility skills
(8
)
0
0
24
2
7
3
4
3
Teach hip safety precautions
Teach safe/effective use of adaptive/assist
device (specify)
Teach safe stair climbing skills
Teach fall safety
Other:
SPEECH THERAPY INTERVENTIONS/INSTRUCTIONS
Evaluation
Establish home maintenance program
❑ Copy given to patient/client
❑ Copy attached to chart
Dysphagia treatments
Safe swallowing evaluation
Language disorders
Speech dysphagia instruction program
Aural rehabilitation
Teach/Develop communication system
Non-oral communication
Other:
Patient/Family education
Alaryngeal speech skills
Voice disorders
Language processing
Speech articulation disorders
Food texture recommendations
OCCUPATIONAL THERAPY INTERVENTIONS/INSTRUCTIONS
Evaluation
Neuro-developmental training
Establish home exercise program
Sensory treatment
❑ Copy given to patient/client
Orthotics/Splinting
❑ Copy attached to chart
Patient/Family education
Independent living/ADL training
Muscle re-education
Perceptual motor training
Fine motor coordination
Adaptive equipment (fabrication
and training)
Therapeutic exercise to right/left hand
to increase strength, coordination,
sensation and proprioception
Teach fall safety
Other:
Teach alternative bathing skills
(unable to use tub/shower safely)
Retraining of cognitive, feeding
and perceptual skills
Form 3492P © 2003 Briggs Medical Service Company (800) 247-2343 www.BriggsCorp.com. The Outcome and ASsessment Information Set (OASIS)
is the intellectual property of the Center for Health Services and Policy Research, Denver, Colorado. It is used with permission.
Page 9 of 13
RECERTIFICATION/
FOLLOW-UP ASSESSMENT
Patient Name______________________________________________________________________________________________________ ID #________________________________________
AMPLIFICATION OF CARE PROVIDED/ANALYSIS OF FINDINGS
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
Patient/Caregiver Response _________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________
m
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HOMEBOUND REASON
❑ Needs assistance for all activities
❑ Residual weakness
❑ Requires assistance to ambulate
❑ Confusion, unable to go out of home alone
❑ Unable to safely leave home unassisted
❑ Severe SOB, SOB upon exertion
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❑ Dependent upon adaptive device(s)
❑ Medical restrictions
❑ Other (specify) ________________________________
SUPERVISORY VISIT: ❑ Yes ❑ NO
SUPERVISORY VISIT: ❑ Scheduled ❑ Unscheduled
STAFF: ❑ Present ❑ Not present
CARE PLAN UPDATED? ❑ No ❑ Yes
CARE PLAN FOLLOWED? ❑ Yes ❑ No (explain) __________________________________________________________________________________________
IS PATIENT/FAMILY SATISFIED WITH CARE? ❑ Yes ❑ No (explain) ________________________________________________________________________
OBSERVATION OF __________________________________________________________________________________________________________________
TEACHING/TRAINING OF ___________________________________________________________________________________________________________
__________________________________________________________________ NEXT SCHEDULED SUPERVISORY VISIT ________/________/________
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SUMMARY CHECKLIST
3
4
3
CARE PLAN: ❑ Reviewed/Revised with patient involvement ❑ Outcome achieved
MEDICATION STATUS: ❑ Medication regimen completed/reviewed (Locator #10)
❑ No change ❑ Order obtained
Check if any of the following were identified:
❑ Potential adverse effects/drug reactions ❑ Ineffective drug therapy ❑ Significant side effects ❑ Significant drug interactions
❑ Duplicate drug therapy ❑ Non-compliance with drug therapy
A
©S
BILLABLE SUPPLIES RECORDED? ❑ Yes
❑ Physician
CARE COORDINATION:
❑ SN
❑ No
❑ PT
❑ OT
❑ ST
4
2
)
❑ MSW
00
REFERRAL TO:_________________________________________________________
RECERTIFICATION:
❑ No, complete discharge summary.
❑ Yes, complete remaining sections, as appropriate.
(8
❑ Aide
2
7
❑ Other (specify) ___________________________________
APPROXIMATE NEXT VISIT DATE ________/________/________
PLAN FOR NEXT VISIT ___________________________________
Verbal Order obtained: ❑ No ❑ Yes, specify date (Locator #23)________/________/________
DME SUPPLIES
(Locator #14)
WOUND CARE:
❑ 2x2’s
❑ 4x4’s
❑ ABD’s
❑ Cotton tipped applicators
❑ Wound cleanser
❑ Wound gel
❑ Drain sponges
❑ Gloves:
❑ Sterile ❑ Non-sterile
❑ Hydrocolloids
❑ Kerlix size ________________
❑ Nu-gauze
❑ Saline
❑ Tape
❑ Transparent dressings
❑ Other ____________________
_________________________
IV SUPPLIES:
❑ IV start kit
❑ IV pole
❑ IV tubing
❑ Alcohol swabs
❑ Angiocatheter size ________
❑ Tape
❑ Extension tubings
❑ Injection caps
❑ Central line dressing
❑ Infusion pump
❑ Batteries size _____________
❑ Syringes size _____________
❑ Other ____________________
_________________________
URINARY/ OSTOMY:
❑ Underpads
❑ External catheters
❑ Urinary bag/pouch
❑ Ostomy pouch (brand, size)
_________________________
❑ Ostomy wafer (brand, size)
_________________________
❑ Stoma adhesive tape
❑ Skin protectant
❑ Other ____________________
_________________________
FOLEY SUPPLIES:
❑ ______Fr catheter kit
(tray, bag, foley)
❑ Straight catheter
❑ Irrigation tray
❑ Saline
❑ Acetic acid
❑ Other ____________________
_________________________
DIABETIC:
❑ Chemstrips
❑ Syringes
❑ Other ____________________
_________________________
_________________________
MISCELLANEOUS:
❑ Enema supplies
❑ Feeding tube:
type_________ size________
❑ Suture removal kit
❑ Staple removal kit
❑ Steri strips
❑ Other ____________________
_________________________
Form 3492P © 2003 Briggs Medical Service Company (800) 247-2343 www.BriggsCorp.com. The Outcome and ASsessment Information Set (OASIS)
is the intellectual property of the Center for Health Services and Policy Research, Denver, Colorado. It is used with permission.
Page 10 of 13
SUPPLIES / EQUIPMENT:
❑ Bathbench
❑ Cane
❑ Commode
❑ Special mattress overlay
_________________________
❑ Pressure relieving device
_________________________
❑ Eggcrate
❑ Hospital bed
❑ Hoyer lift
❑ Enteral feeding pump
❑ Nebulizer
❑ Oxygen concentrator
❑ Suction machine
❑ Ventilator
❑ Walker
❑ Wheelchair
❑ Tens unit
❑ Other ____________________
_________________________
RECERTIFICATION/
FOLLOW-UP ASSESSMENT
Patient Name______________________________________________________________________________________________________ ID #________________________________________
PROFESSIONAL SERVICES
Locator #21
Complete this section only when 485 / POC is completed
Emergency Code: _________________________
Check and specify patient
specific orders for POC
❑ DNR - Do Not Resuscitate
(must have MD order)
SN - FREQUENCY / DURATION ____________
❑ Skilled Observation for ___________________
_______________________________________
❑ Evaluate Cardiopulmonary Status
❑ Evaluate Nutrition / Hydration / Elimination
❑ Evaluate for S/S of Infections
❑ Teach Disease Process
❑ Teach S/S of Infection and Standard
Precautions
❑ Teach Diet
❑ Teach Home Safety / Falls Prevention
❑ Other __________________________________
❑ PRN Visits for ___________________________
❑ Psychiatric Nursing for ___________________
MEDICATIONS
❑ Medication Teaching
❑ Evaluate Med Effects / Compliance
❑ Set up Meds Every ____ Weeks
❑ Administer medication(s) (name, dose,
route, frequency)________________________
_______________________________________
_______________________________________
❑ Administer medication(s) (name, dose,
route, frequency)________________________
_______________________________________
_______________________________________
❑ Administer medication(s) (name, dose,
route, frequency)________________________
_______________________________________
_______________________________________
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❑
❑
❑
❑
❑
❑
Teach S/S of IV Complications
Teach IV Site Care
Teach Infusion Pump
Teach Complete Parenteral Nutrition
Site Care (specify) _______________________
Line Protocol (specify) ___________________
_______________________________________
❑ ___PRN Visits for IV Complications
❑ Anaphylaxis Protocol (specify orders)
_______________________________________
_______________________________________
_______________________________________
❑ Other __________________________________
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FLUSHING PROTOCOL /
FREQUENCY (specify)
❑ Administer Flush(es) _____________________
___ml normal saline
___________________________________
___ml normal saline
___________________________________
___ml sterile water
___________________________________
___ml heparin ___unit /ml
___________________________________
___ml heparin ___unit /ml
___________________________________
___________________________________
___________________________________
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INTEGUMENTARY
❑ Wound Care (specify each site) ___________
_______________________________________
_______________________________________
❑ Evaluate Wound / Decub for Healings
❑ Measure Wound(s) Weekly
❑ Teach Wound Care / Dressing
❑ Other __________________________________
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IV
❑ Administer IV medication (name, dose,
route, frequency and duration)____________
_______________________________________
_______________________________________
_______________________________________
❑ Teach IV Administration__________________
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RESPIRATORY
❑ O2 at __________ liters per ________ minute
❑ Pulse Oximetry: Every Visit
❑ Pulse Oximetry: PRN Dyspnea
❑ Teach Oxygen Use / Precautions
❑ Teach Trach Care
❑ Administer Trach Care
❑ Other __________________________________
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0
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GASTROINTESTINAL
❑ Teach N / G Tube Feeding
❑ Teach G-Tube Feeding
❑ Other __________________________________
DIABETES
❑ Administer Insulin
❑ Prepare Insulin Syringes
❑ Blood Glucose Monitoring PRN or ________
❑ Teach Diabetic Care
❑ Other __________________________________
MATERNAL /CHILD
❑ Evaluate Fetal / Maternal Status
❑ Evaluate Growth and Development
❑ Evaluate Parenting
❑ Teach S/S of Preterm Labor
❑ Teach Growth and Development
❑ Teach Apnea Monitor Use
❑ Other __________________________________
PT - FREQUENCY/DURATION ____________
❑ Evaluation and Treatment
❑ Pulse Oximetry PRN
❑ Home Safety / Falls Prevention
❑ Therapeutic Exercise
❑ Transfer Training
❑ Gait Training
❑ Establish Home Exercise Program
❑ Modality (specify frequency, duration,
(amount) _______________________________
_______________________________________
❑ Prosthetic Training
❑ Muscle Re-Education
❑ Other __________________________________
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ELIMINATION
❑ Foley ___________ French inflated balloon
with _____ml changed every ______________
❑ Suprapubic Cath Insertion every __________
❑ Teach Care of Indwelling Catheter
❑ Teach Self - Cath
❑ Teach Ostomy Care
❑ Teach Bowel Regime
❑ Other __________________________________
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LABORATORY
❑ Venipuncture for _________________________
❑ Other __________________________________
OT - FREQUENCY/DURATION _____________
❑ Evaluation and Treatment
❑ Pulse Oximetry PRN
❑ Home Safety /Falls Prevention
❑ Adaptive Equipment
❑ Therapeutic Exercise
❑ Muscle Re-Education
❑ Establish Home Exercise Program
❑ Homemaker Training
❑ Modality (specify frequency, duration,
(amount) _______________________________
_______________________________________
❑ Other __________________________________
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4
3
ST - FREQUENCY/DURATION_____________
❑ Evaluation and Treatment
❑ Voice Disorder Treatment
❑ Speech Articulation Disorder Treatment
❑ Dysphagia Treatment
❑ Receptive Skills
❑ Expressive Skills
❑ Cognitive Skills
❑ Other __________________________________
HOME HEALTH AIDE FREQUENCY/ DURATION _________________
❑ Personal Care for ADL Assistance
❑ Other (specific task for HHA) _____________
_______________________________________
_______________________________________
OTHER SERVICES (specify) ________________
FREQUENCY/ DURATION _________________
❑ Homemaking
❑ Other __________________________________
MSW - FREQUENCY/DURATION __________
❑ Evaluate and Treat
❑ Evaluate Family Situation
❑ Evaluate / Refer to Community Resources
❑ Evaluate Financial Status
❑ Other __________________________________
Form 3492P © 2003 Briggs Medical Service Company (800) 247-2343 www.BriggsCorp.com. The Outcome and ASsessment Information Set (OASIS)
is the intellectual property of the Center for Health Services and Policy Research, Denver, Colorado. It is used with permission.
Page 11 of 13
RECERTIFICATION/
FOLLOW-UP ASSESSMENT
Patient Name______________________________________________________________________________________________________ ID #________________________________________
REHABILITATION POTENTIAL / GOALS
Locator #22
Check goal(s), circle for specifics and insert information.
DISCIPLINE GOALS AND DATE WILL BE ACHIEVED
Nursing:
Occupational Therapy:
❑ Demonstrates compliance with medication
by _______________ (date)
❑ Demonstrates ability to follow home exercise program by
_________________ (date)
❑ Stabilization of cardiovascular pulmonary condition
by _______________ (date)
❑ Other_____________________________ by _________________ (date)
Speech Therapy:
❑ Demonstrates competence in following medical regime
by _________________ (date)
❑ Demonstrate swallowing skills in formal / informal dysphagia
evaluation exercise program by _________________ (date)
❑ Verbalizes pain controlled at acceptable level
by _________________ (date)
❑ Completes speech therapy program
by _________________ (date)
❑ Demonstrates independence in _______________________________
by _________________ (date)
❑ Verbalize s/ Demonstrates independence with care
by _________________ (date)
Aide:
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❑ Other_____________________________ by _________________ (date)
Medical Social Services:
❑ Verbalize information about community resources and how to obtain
assistance by _________________ (date)
❑ Other__________________________ by _________________ (date)
❑ Demonstrates ability to follow home exercise program
by _________________ (date)
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❑ Other_____________________________ by _________________ (date)
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DISCHARGE PLANS
❑ Return to an independent level of care (self-care)
4
2
)
2
7
❑ Able to remain in residence with assistance of primary caregiver / support from community agencies
❑ When patient knowledgeable about when to notify physician
❑ Able to understand medication regime and care related to diagnoses
❑ Medical condition stabilizes
❑ When maximum functional potential reached
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❑ Other____________________________ by _________________ (date)
❑ Expect daily SN visits to end by _________________ (date)
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❑ Assumes responsibility for personal care needs
by _________________ (date)
❑ Wound healing without complications
by ________________ (date)
Physical Therapy:
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❑ Other_____________________________ by _________________ (date)
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0
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3
4
3
❑ Other_______________________________________________________________
❑ Other_______________________________________________________________
DISCUSSED WITH PATIENT: ❑ Yes ❑ No
REHAB POTENTIAL: ❑ Poor ❑ Fair ❑ Good ❑ Excellent
SIGNATURE /DATES
X
____________________________________________________________________________________________________
________/________/________
Patient/ Caregiver (if applicable)
Date
X
____________________________________________________________________________________________________
________/________/________
Person Completing This Form (signature/title)
Date
OASIS INFORMATION
Date Reviewed________/________/________ Date Entered & Locked________/________/________
Date Transmitted________/________/________
Form 3492P © 2003 Briggs Medical Service Company (800) 247-2343 www.BriggsCorp.com. The Outcome and ASsessment Information Set (OASIS)
is the intellectual property of the Center for Health Services and Policy Research, Denver, Colorado. It is used with permission.
Page 12 of 13
RECERTIFICATION/
FOLLOW-UP ASSESSMENT
Patient Name______________________________________________________________________________________________________ ID #________________________________________
X
CARE SUMMARY
Dear Doctor______________________________________________
This Care Summary, page 13 of 13, is your ❑ Recertification (follow-up) ❑ Other Follow-up
Thank you for allowing us to care for your patient.
Disciplines Involved
Comments
❑ SN
❑ PT
❑ OT
❑ ST
❑ MSW
❑ Aide_______________
❑ Other______________
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Physician notified: ❑ Yes ❑ No
Date of last home visit________/________/________
❑ POT485 attached for signature. Please sign and return.
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❑ Copy of Care Summary sent / faxed (circle) Date:__________________
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SUMMARY
Complete this Section for Recertification (Unless Summary is written elsewhere)
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REASON FOR ADMISSION (describe condition) ____________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
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________________________________________________________________________________________________________________________
SUMMARY OF CARE (including progress toward goals to date) ______________________________________________________________________
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7
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
4
2
)
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
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0
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________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
DISCHARGE PLANNING (specify future follow-up, referrals, etc.) _____________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Signature/Title of
Person Completing This Form_________________________________________________________________ Date________/________/________
Agency Name_____________________________________________________________________ Phone #_____________________________
ORIGINAL — Clinical Record
(Provide copy to Physician per agency policy)
Form 3492P © 2003 Briggs Medical Service Company (800) 247-2343 www.BriggsCorp.com. The Outcome and ASsessment Information Set (OASIS)
is the intellectual property of the Center for Health Services and Policy Research, Denver, Colorado. It is used with permission.
Page 13 of 13
RECERTIFICATION/
FOLLOW-UP ASSESSMENT