SN Disc

hemanth
branch1 address, Schenectady, NY 12345
OASIS - Discharge from Agency

Client: Mr assign1, assign1
SOC: 01/02/2016
Episode: 2 -- 03/02/2016 - 04/19/2016
Visit Date: 04/19/2016
Check In Time: 09:00 AM
Check Out Time: 10:00 AM
Patient Tracking
(M0050) Patient State of Residence: NY
(M0060) Patient Zip Code: 12345
(M0010) CMS Certification Number:

(M0014) Branch State: NY
(M0016) Branch ID Number: N
(M0063) Medicare Number: 1234567890 o NA
(M0018) NPI for the Attending Physician: 1233333423

(M0020) Patient ID Number: 5000
(M0064) Social Security Number: UK

(M0065) Medicaid Number: NA
(M0066) Birth Date: 01/01/1998
(M0030) Start of Care Date: 01/02/2016
(M0069) Gender: Male
(M0032) Resumption of Care Date:

(M0040) Patient Name: Mr assign1, assign1
(M0140) Race/Ethnicity: 2 - Asian
(M0150) Current Payment Sources for Home Care: 1 - Medicare (traditional fee for service)
Clinical Record Items

(M0080) Discipline of Person Completing Assessment:
1 - RN
o 2 - PT
o 3 - SLP/ST
o 4 - OT
(M0090) Date Assessment Completed: 04/21/2016

(M0100) This Assessment is Currently Being Completed for the Following Reason:
o 1 - Start of Care - further visits planned

o 6 - Transferred to an inpatient facility-patient not discharged from agency [Go to M0141]
o 3 - Resumption of care (after inpatient stay)
o 7 - Transferred to an inpatient facility-patient discharged from agency [Go to M1041]
o 4 - Recertification (follow-up) reassessment [Go to M0110] o 8 - Death at home [Go to M0903]
o 5 - Other follow-up [Go to M0110]
9 - Discharge from Agency [Go to M1041]
Page 1 of 33

Printed Date: 09/07/2016
SOC: 01/02/2016
Episode: 2 -- 03/02/2016 - 04/19/2016
Patient History & Diagnosis

(M1041) (Check one)
Influenza Vaccine Data Collection Period: Does this episode of care (SOC/ROC to Transfer/Discharge) include any dates on or between October 1
and March 31?
0 - No [Go to M1051]
o 1 - Yes
(M1046) (Check one)

Influenza Vaccine received: Did the patient receive the influenza vaccine for thisyear's flu season?
o 1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)
o 2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)
o 3 - Yes; received from another health care provider (for example, physician, pharmacist)
o 4 - No; patient offered and declined
o 5 - No; patient assessed and determined to have medical contraindication(s)
o 6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine
o 7 - No; inability to obtain vaccine due to declared shortage
o 8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4 - 7
(M1051) (Check one)
Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV from your agency during this episode or care
(SOC/ROC to Transfer/Discharge)) ?
0 - No
o 1 - Yes [Go to M1500 at TRN; Go to M1230 at DC ]
(M1056) Reason Pneumococcal Vaccine not received:

If patient has never received the pneumococcal vaccination (for example, pneumovax), state reason:
1 - Offered and declined

o 2 - Assessed and determined to have
medical contraindication(s)
o 3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine
o 4 - None of the above
Patient Herpes Zoster (Shingles) vaccine status

o Received prior to SOC from another provider
Did Agency Offer?
o Yes
o No
Patient Contact with Physician
Reason for contact: asf

Date last contacted: 09/01/2016
Reason for visit: af
Date last visited:
(face to face)
Vital Signs
Height:
o Actual o Stated
BP:
Lying:
Sitting:
Left: /
/
Right: /
/
Notify Physician of:
Temperature greater than(>)
Pulse greater than(>)
Respirations greater than(>)
Systolic BP greater than(>)
Diastolic BP greater than(>)
Weight:
lbs.
Temp: F
Pulse:
Standing:
/
/
or less than(<)
or less than(<)
or less than(<)
or less than(<)
or less than(<)
Apical:
Radial:
Resp:
o Oral o Axillary o Rectal o Tympanic o Temporal Artery

o At Rest o Activity
o (reg) o (Irreg)
o (reg) o (Irreg)
o (reg) o (Irreg)
o At Rest o Activity
O2 Sat less than(<)

Pain greater than(>)
Fasting blood sugar greater than(>)
Random blood sugar greater than(>)
Weight greater than(>)
Advance Directives
Page 2 of 33
%
or less than(<)
or less than(<)
or less than(<)
lbs. or less than(<)

Printed Date: 09/07/2016
SOC: 01/02/2016
Episode: 2 -- 03/02/2016 - 04/19/2016
Patient History & Diagnosis

o Living will o Education needed o Do not resuscitate o Copies on file o Organ donor o Funeral arrangements made o POA
o Healthcare representative
Comments:
Prior Hospitalizations
o No o Yes
Reason(s)/Date(s):
Number of times:
Primary Reason for Home Health
asdfasf
Page 3 of 33

SOC: 01/02/2016
Episode: 2 -- 03/02/2016 - 04/19/2016
Sensory Status
Eyes/Vision
o N/A o No Problem Found

Glasses
o Cataract surgery(site):
o Contacts:
o Jaundice
o Prosthesis:
o Ptosis
Glaucoma
o Infections:
Blurred Vision
o Blind:
o Other (specify):
How does the impaired vision interfere / impact their function / safety? (explain):
Nose

Congestion o Epistaxis o Loss of smell o Sinus problem
o Other (specify):
Throat

Dysphagia o Hoarseness o Lesions o Sore throat o Other (specify):
Ears

o HOH: o Deaf: o Hearing aid:
o Other (specify):
o Vertigo o Tinnitus:
Mouth

Dentures: o Upper o Lower o Partial o Masses/Tumors o Gingivitis o Ulcerations o Toothache
o Other (specify):
(M1230)
Speech and Oral (Verbal) Expression of Language (in patient's own language):
0 - Express complex ideas, feelings and needs clearly, completely and easily in all situations with no observable impairment.
o 1 - Minimal difficulty in expressing ideas and needs (may take extra time; makes occasional errors in word choice, grammar or speech
intelligibility; needs minimal prompting or assistance).
o 2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech
intelligibility). Speaks in phrases or short sentences.
o 3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener. Speech limited to single
words or short phrases.
o 4 - Unable to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical
or unintelligible.)
o 5 - Patient nonresponsive or unable to speak.
Musculoskeletal

Arthritis o Atrophy o Contractures o Deformities o Gout o Swollen joints o Abnormal gait o Decreased ROM o Weakness
o Joint pain o Leg cramps o Numbness o Amputation o Paralysis o History of fracture o History of joint replacement
o Prosthesis, appliance, etc. o Other (specify):
Notes:
(M1242)
Frequency of Pain Interfering with patient's activity or movement:
0 - Patient has no pain

o 1 - Patient has pain that does not interfere with activity or movemen
o 2 - Less often than daily
Page 4 of 33
o 3 - Daily, but not constantly

o 4 - All of the time

SOC: 01/02/2016
Episode: 2 -- 03/02/2016 - 04/19/2016
Integumentary
(M1306) ( Check One )
Does this patient have atleast one Unhealed Pressure Ulcer at Stage II or Higher or designated as "unstageable"?(Excludes Stage I pressure
ulcers and healed Stage II pressure ulcers)
0 - No [Go to M1322]
(M1307)
o 1 - Yes
The Oldest Non-epithelized Stage II Pressure Ulcer that is present at discharge: (Excludes healed Stage II Pressure Ulcers)
o 1 - Was present at the most recent SOC/ROC assessment
o 2 - Developed since the most recent SOC/ROC assessment
o NA - No Stage II pressure ulcers are present at discharge
(M1308)
Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Each Stage: (Enter "0" if none; excludes Stage | pressure ulcers and healed Stage II
pressure ulcers)
Complete at SOC/ROC/FU & D/C
Number Currently Present
Stage description - unhealed pressure ulcers
a). Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer
with red pink wound bed, without slough. May also present as an intact or
open/ruptured serum-filled blister.
b). Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but
bone, tendon, or muscles are not exposed. Slough may be present but does not
obscure the depth of tissue loss. May include undermining and tunneling.
c). Stage IV: Full thickness tissue loss with visible bone, tendon, or muscle.
Slough or eschar may be present on some parts of the wound bed. Often
includes undermining and tunneling.
d.1). Unstageable: Known or likely but unstageable due to non-removable
dressing or device.
d.2). Unstageable: Known or likely but unstageable due to coverage of wound
bed by slough and/or eschar.
d.3). Unstageable: Suspected deep tissue injury in evolution.
Page 5 of 33

SOC: 01/02/2016
Episode: 2 -- 03/02/2016 - 04/19/2016
Integumentary
(M1309)
Worsening in pressure Ulcer Status since SOC/ROC:
Instructions for a - c: For Stage II, III and IV pressure ulcers, report number that are new or have increased in numerical stage since the most recent
SOC/ROC
Enter Number
(Enter "0" if there are no current Stage II, III or IV
pressure ulcers OR if all current Stage II, III or IV
pressure ulcers existed at the same numerical
a). Stage II
b). Stage III
c). Stage IV
Instructions for d: For Pressure pressure taht are unstageable due to slough/eschar, report the number that are new or were a Stage I or II at the most
recent SOC/ROC.
Enter Number
(Enter "0" if there are no unstageable pressure
ulcers at discharge OR if all current unstageable
pressure ulcers were stage III or IV or were
d). Unstageable: Known or likely but unstageable

due to coverage of wound bed by slough and/or
(M1320)
Status of Most Problematic Pressure Ulcer that is Observable: (Excludes pressure ulcer that cannot be observed due to a non-removable
dressing/device)
o 0 - Newly epithelialized
o 1 - Fully granulating
o 2 - Early/partial granulating
o 3 - Not Healing
o NA - No observable pressure ulcer
(M1322)
Current Number of Stage | Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may
be painful, firm, soft, warmer or cooler as compared to adjacent tissue
o1
o2
o3
o 4 or more
(M1324)
Stage of Most Problematic Unhealed (Observable) Pressure Ulcer: (Excludes pressure ulcer that cannot be staged due to a non-removable
dressing/device, coverage of wound bed by slough and/or eschar, or suspected deep tissue injury.)
o 1 - Stage I
o 2 - Stage II
o 3 - Stage III
o 4 - Stage IV
NA - Patient has no pressure ulcers or no stageable pressure ulcers
(M1330)
Does this patient have a Stasis Ulcer?

0 - No [Go to M1340]
o 1 - Yes, patient has both observable and unobservable stasis ulcer
o 2 - Yes, patient has observable stasis ulcer only

o 3 - Yes, patient has unobservable stasis ulcer only (known but not
observable due to non-removable dressing.device) [Go to M1340]
(M1332)
Current Number of (Observable) Stasis Ulcer(s):
o 1 - One
o 2 - Two
o 3 - Three
o 4 - Four or More
(M1334)
Status of Most Problematic (Observable) Stasis Ulcer:
o 3 - Not Healing
Page 6 of 33

SOC: 01/02/2016
Episode: 2 -- 03/02/2016 - 04/19/2016
Integumentary
(M1340)
Does this patient have a Surgical Wound ?

0 - No
[Go to M1400]
o 1 - Yes, patient has atleast one (observable) surgical wound
o 2 - Surgical wound known but not observable due to non-removable dressing
[Go to M1400]
(M1342)
Status of Most Problematic Surgical Wound that is Observable:
o 0 - Newly epithelialized
o 3 - Not Healing
Skin
o N/A
No problem Found
Skin Color
Temp
o Pale
o Hot
o Jaundiced
o Cool
o Cyanotic
o Diaphoretic
o Ecchymosis
o Warm
Turgor
Lesions
o Good
o Poor
o Wounds
o Incision
o Ostomy
o Ulcers
o Rashes
o Other (specify):
Nails
o N/A
No problem Found
o Poor nail care
o Ingrown (describe):
o Other (specify):
o Diabetic foot care performed (skip, if not diabetic)
o Current diabetic skin lesion/location
o Foot care education this visit or planned for future visits
Notes:
Page 7 of 33
o Bruises
o Itching
o Petechiae
o Purpura
o Dry
o Scaling
o Redness
o Pallor

SOC: 01/02/2016
Episode: 2 -- 03/02/2016 - 04/19/2016
Respiratory Status
(M1400)
When is the patient dyspneic or noticeably Short of Breath ?

0 - Patient is not short of breath
o 1 - When walking more than 20 feet, climbing stairs
o 2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)
o 3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation
o 4 - At rest (during day or night)
o Assessed o Reported
Respiratory
o N/A No Problem Found

Breath Sounds:
Anterior
Right:
Left:
Posterior
Right Upper:
Right Lower:
Left Upper:
Left Lower:
o Other:
o Accessory muscle used
O2 @: LPM via o Cannula o Mask o Trach
O2 saturation:
%
Trach size/type:
Who manages? o Self o RN o Clinician/family o Other:
Intermittent treatments (C&DB, medicated inhalation treatments, etc.)
o No o Yes, explain:
Cough:
o No o Yes
o Productive o Non-productive
Describe:
Dyspnea:
o Rest o During ADL's
Comments:
Positioning necessary for improved breathing
o No
o Yes, describe:
Page 8 of 33
Page 9 of 33

SOC: 01/02/2016
Episode: 2 -- 03/02/2016 - 04/19/2016
Cardiac Status
(M1500) Symptoms in Heart Failure Patients:
If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including
dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the previous OASIS assessment ?
0 - No [Go to M2004 at TRN; Go to M1600 at DC ]

o 1 - Yes
o 2 - Not assessed [Go to M2004 at TRN; Go to M1600 at DC ]
o NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC ]
(M1510) (Mark all that apply)
Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure at the time of or at
any time since the previous OASIS assessment, what action(s) has (have) been taken to respond ?
o 0 - No action taken
o 1 - Patient's physician (or other primary care practitioner) contacted the same day.
o 2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room).
o 3 - Implemented physician-ordered patient-specific established parameters for treatment
o 4 - Patient education or other clinical interventions
o 5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth., etc.)
Cardiovascular

Heart Sounds: o Regular o Irregular
o Murmur
o Pacemaker:
Date:
Last date checked:
Type:
o Chest Pain:
Anginal
o Substernal
o Ache
Postural
o Radiating
o Sharp
o Localized
o Dull
o Vise-like
Frequency/duration:
o Palpitations o Fatigue
o Edema
o Pedal Right o Left
o Dependent:
o Sacral
o Pitting
o Non-pitting
RLE: 1+ o 2+ o 3+ o 4+
RLE: o
LLE: 1+ o 2+ o 3+ o 4+
LLE: o
o Cramps Claudication
o Capillary refill: less than 3 sec o more than 3 sec
Comments:
Disease Management Problems (explain):
Page 10 of 33
Associated with
o Shortness of Breath
o Sweats
How relieved:
o Activity

SOC: 01/02/2016
Episode: 2 -- 03/02/2016 - 04/19/2016
Elimination Status
Genitourinary
N/A
o No Problem Found
o Urgency/frequency
o Hesitancy
o Hematuria
o Burning/pain
o Nocturia
o Oliguria/anuria
o Urinary Incontinence (when occurs):
o Diapers/other:
Color:
o Yellow/straw o Amber o Brown/gray o Blood-tinged
o Other:
Clarity:
o Clear o Cloudy o Sediment/mucous
Odor:
o Yes o No
Urinary Catheter:
Type:
Date last changed:
o Foley inserted (date):
with French
Inflated balloon with
ml
o without difficulty o Suprapubic
Irrigation solution: Type (specify):
Amount:
ml Frequency:
Patient tolerated procedure well
o Yes o No
o Urostomy (describe skin around stoma):
Ostomy care managed by: o Self o Caregiver
o Other (specify):
Disease Management Problems Explain:
o Hx UTIs
Returns:
Genitalia
o N/A
o No Problem Found
o Discharge/Drainage: (describe)
o Lesions/Blisters/Masses/Cysts
o Inflammation
o Prostate problem: BPH/TURP Date:
o Self-testicular exam. Frequency:
o Menopause
Date last PAP:
o Breast self-exam, frequency:
o Mastectomy: R/l Date
o Other (specify):
o Surgical alteration
o Hysterectomy Date:
Results:
o Discharge: R/l
(M1600)
Has this patient been treated for a Urinary Tract Infection in the past 14 days ?
0 - No o 1 - Yes o 2 - NA - Patient on prophylactic treatment o UK - Unknown
(M1610)
Urinary Incontinence or Urinary Catheter Presence:
0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Go to M1620]
o 1 - Patient is incontinent
o 2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [Go to M1620]
(M1615)
When does Urinary Incontinence occur ?

o 0 - Timed-voiding defers incontinence
o 1 - Occasional stress incontinence
o 2 - During the night only

o 3 - During the day only
Page 11 of 33
o 4 - During the day and night

SOC: 01/02/2016
Episode: 2 -- 03/02/2016 - 04/19/2016
Elimination Status
(M1620)
Bowel Incontinence Frequency:
0 - Very rarely or never has bowel incontinence

o 1 - Less than once weekly
o 2 - One to three times weekly
o 3 - Four to six times weekly
o 4 - On a daily basis
o 5 - More often than once daily
o NA - Patient has ostomy for bowel elimination
o UK - Unknown
Gastrointestinal
o N/A
No Problem Found
o Nausea
o Constipation
o Vomiting
o Impaction
o Diarrhea
o Flatulence
o Other (specify):
Frequency of stools:
o Melena
o Rectal bleeding
o Hemorrhoids
o Ulcers
o Hernias
o Gall bladder problem
Bowel Sounds
o Absent
o Hypoactive:
o Hyperactive:
o Active:
Abdomen
o Distention o Hard o Soft o Pain w/Palpation o Tenderness
o Abdominal girth: cm.
o Other:
Laxative/Enema use:
o Daily o Weekly o Monthly
o Other:
Frequency:
o Frequent BMs:
o Infrequent BMs: days since last
Bowel regime/program:
o Ascites
o Last BM Date:
Endocrine/ Hematology
o N/A
No Problem Found
o Diabetes:
o Type I Juvenile
o Type II
o Other endocrine disorder (specify):
o Diet/Oral control (specify):
o Insulin dose/frequency (specify):
On insulin since:
Medication Management:(select primary person responsible)
Insulin drawn up by:
o Patient
o Nurse
Insulin administered by:
o Patient
o Nurse
Monitored by:
o Patient
o Nurse
Hyperglycemic S&S
o Glycosuria/Polyuria/Polydipsia
Hypoglycemic S&S
o Sweats/Polyphagia/Weak/Faint/Stupor
A1c %
o Patient o Caregiver o Lab slip
Most Recent FBS/BS (mg/dl)
Date:
o FBS o Before Meal o Postprandial o Random HS
Reported By: o Nurse
o Other:
Normal BS Range (mg/dl)
Low
To High
Monitored By: o Self o Caregiver o Nurse
o Other:
Blood Sugar Frequency times per
Competency with the use of Glucometer:
o Disease management problems (describe):
Date of Onset:
o Caregiver
o Caregiver
o Caregiver
Page 12 of 33
o Other:
o Other:
o Other:
o Indigestion
o Pain
o Jaundice

SOC: 01/02/2016
Episode: 2 -- 03/02/2016 - 04/19/2016
Elimination Status
o Enlarged Thyroid o Fatigue o Intolerance to heat/cold

o Other (specify):
Secondary bleed
o GI o GYN o GU o Unknown
o Anemia (specify if known):
o Hemophilia(describe):
o Other blood dyscrasias:
Page 13 of 33

SOC: 01/02/2016
Episode: 2 -- 03/02/2016 - 04/19/2016
Nutritional Status
o N/A
o No Problem Found
NUTRITIONAL HEALTH SCREEN
Points
YES
Unintentional weight loss > 10lbs in 3 months
12
12
Drinks 3 or more alcoholic beverages almost everyday
Eats fewer than 2 meals per day
Emotional issues/Eating disorder
Limited access to food
Chewing and/or swallowing problems
Unable to cook/shop/feed-self independently
Eats fewer than 2-3 servings of fruits/vegetables a day
Frequent diarrhea/constipation problems
Takes 3 or more prescribed or over-the-counter drugs a day
Eats alone most of the time
Has an open: o Decubitus o Ulcer o Wound
o Burn
Total: 80
INTERPRETATION
0-20 Good Nutritional Status: As appropriate reassess and/or provide information based on situation.
24-44 Moderate Nutritional Risk: Educate, refer, monitor and reevaluate based on patient situation and organization policy
48-80 High Nutritional Risk: Coordinate with physician, dietitian, social service professional or nurse about how to improve nutritional health.
Reassess nutritional status and educate based on plan of care.
Nutritional Status Comments:
oNon-compliant with prescribed Diet

oOver/Under Weight by 10%
Meals Prepared by:
Avg. Fluid Intake(8 oz. Glasses/Day):
Weight change in Last 6 Mos.: lbs. oLost oGained
Nutritional Requirements
Sodium Diet: 5
o Calorie ADA Diet:
o Bland Diet:
o Protein Hi Diet:
o Protein Low Diet:
o Carbohydrate Hi Diet:
o Carbohydrate Low Diet:
o Enteral feeding:
o Mechanical (Soft, Hi-Fiber, etc.):
o NG Tube:
o Regular:
o PEG Tube:
o No Concentrated Sweets:
o Tube:
o No Added Salt:
o NPO:
o Other (specify):
Page 14 of 33

SOC: 01/02/2016
Episode: 2 -- 03/02/2016 - 04/19/2016
Nutritional Status
Enteral Feedings - Access Device
o N/A
o No Problem Found
o Nasogastric o Gastrostomy o Jejunostomy
Other (specify): asdf
Pump (type/specify):saf
o Bolus o Continuous
Feedings: Type (amt./rate):
Flush Protocol: (amt./specify):
Performed by: o Self o RN o Caregiver o Other
Dressing/Site care:
Instructions/Comments:
Page 15 of 33

SOC: 01/02/2016
Episode: 2 -- 03/02/2016 - 04/19/2016
Neuro/Emotional/Behavioral Status
Mental Status
Oriented
o Comatose
o Other (specify):
o Forgetful
o Depressed
o Disoriented
o Lethargic
o Agitated
Neuro, Emotional, Behavioral Problems
o N/A
o No Problem Found
Dominant Side:
PERRLA
Headache
Dizziness
o Other (specify):
Headache: Location:
Frequency:
o Unequal grip
o UE weakness
o LE weakness
o Tremors
o Fine motor change
o Gross motor change
Affect
o Labile
o Flat Affect
o Receptive aphasia
o Expressive aphasia
o Unequal Pupils R/L
Sleep/Rest
o Withdrawn
o Lethargic
o Stuporous
o Unresponsive
o Inadequate
o Nightmares
Memory
o Adequate
Psychosocial Problems
o N/A
o No Problem Found
Angry
o Difficulty Coping
o Indecisive
Mania
o Discouraged
o Lack of concentration
Hallucinations
o Disorganized
o Other (describe below)
o Flat affect
o Withdrawn
o Depressed: o Recent o Long term
Treatment:
Coping with change
Inappropriate response to
o Role
o Caregiver
o Body image
o Clinician
o Sexual
o Follow-through on tasks
Language
Primary Language
o Language barrier: o Unable to read o Unable to write o Needs Interpreter
o Learning Barrier: o Mental o Psychosocial o Physical o Functional
o Unable to read/write Education level:
Deficits:
Describe above abnormal findings
o Spiritual/Cultural implications that impact care.
Spiritual resource/Phone no:
Explain:
o Inability to cope with altered health status as evidenced by:
o Lack of motivation o Inability to recognize problems o Unrealistic expectations o Denial of problems
o Sleep Rest: o Adequate o Inadequate
Explain:
o Inappropriate reasons to caregiver/clinician o Inappropriate follow-through in past
o Evidence of abuse/neglect/exploitation: o Potential o Actual o Verbal/Emotional o Physical o Financial
o Other (Specify)
Page 16 of 33
o Short term memory deficit

o Long term memory deficit

SOC: 01/02/2016
Episode: 2 -- 03/02/2016 - 04/19/2016
Neuro/Emotional/Behavioral Status
Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate
memory for simple commands.
0 - Alert/Oriented, able to focus and shift attention, comprehends and recalls task directions independently.
o 1 - Requires prompting (cuing, repetition, reminders) only under stressful or unfamiliar conditions.
o 2 - Requires assistance and some direction in specific situations (e.g., on all tasks involving shifting of attention), or consistently requires low
stimulus environment due to distractibility.
o 3 - Requires considerable assistance in routine situations. Is not alert and oriented or is unable to shift attention and recall directions more
than half the time.
o 4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.
(M1710)
When Confused (Reported or Observed Within the Last 14 Days):
0 - Never.
o 1 - In new or complex situations only.
o 2 - On awakening or at night only
o 3 - During the day and evening, but not constantly.
o 4 - Constantly
o NA - Patient nonresponsive
(M1720)
When Anxious (Reported or Observed Within the Last 14 Days):
0 - None of the time.

o 1 - Less often than daily.
o 2 - Daily, but not constantly
o 3 - All of the time.
o NA - Patient nonresponsive
(M1740) ( Mark all that apply. )
Cognitive, behavioral, and psychiatric symptoms that are demonstrated atleast once a week (Reported or Observed):
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
o 2 - Impaired decision-making: failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions
o 3 - Verbal disruption: yelling, threatening, excessive profanity, sexual references, etc.
o 4 - Physical aggression: aggressive or combative to self and others (e.g., hits self, throws objects, punches, dangerous maneuvers with
wheelchair or other objects)
o 5 - Disruptive, infantile, or socially inappropriate behavior (excludes verbal actions)
o 6 - Delusional, hallucinatory, or paranoid behavior
o 7 - None of the above behaviors demonstrated
(M1745)
Frequency of Disruptive Behavior Symptoms (Reported or Observed)Any physical, verbal, or other disruptive/dangerous symptoms that are
injurious to self or others or jeopardize personal safety
0 - Never.
o 2 - Once a month.
o 4 - Several times a week
o 1 - Less than once a month.

o 3 - Several times each month.
o 5 - Atleast daily
Page 17 of 33

SOC: 01/02/2016
Episode: 2 -- 03/02/2016 - 04/19/2016
ADLs & IADLs

Grooming: Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or make up, teeth or denture
care, fingernail care).
0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.
o 1 - Grooming utensils must be placed within reach before able to complete grooming activities.
o 2 - Someone must assist the patient to groom self.
o 3 - Patient depends entirely upon someone else for grooming needs.
Current Ability to Dress Upper Body: Safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and
blouses, 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.
o 1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.
o 2 - Someone must help the patient put on upper body clothing.
o 3 - Patient depends entirely upon another person to dress the upper body
Current Ability to Dress Lower Body: Safely (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.
o 1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.
o 2 - Someone must help the patient put on undergarments, slacks, socks or nylons, shoes.
o 3 - Patient depends entirely upon another person to dress the lower body
Bathing Current ability to wash entire body safely. Excludes grooming (washing face, washing hands, and shampooing hair):
0 - Able to bathe self in shower or tub independently, including getting in and out of tub/shower.
o 1 - With the use of device, is able to bathe self in shower or tub independently, including getting in and out of tub/shower.
o 2 - Able to bathe in shower or tub with the intermittent assistance of another person: 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.
o 3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision
o 4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode
o 5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the
assistance or supervision of another person throughout the bath.
o 6 - Unable to participate effectively in bathing and is bathed totally by another person.
Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.
0 - Able to get to and from the toilet and transfer independently with or without a device.
o 1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.
o 2 - Unable to get to and from the toilet but is able to use a bedside commode with or without assistance.
o 3 - Unable to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.
o 4 - Is totally dependent in toileting.
Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet,
commode, bedpan, urinal. If managing ostomy, includes cleaning area around stoma, but not managing equipment.
0 - Able to manage toileting hygiene and clothing management without assistance.

o 1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.
o 2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.
o 3 - Patient depends entirely upon another person to maintain toileting hygiene.
Transferring: Current ability to move safely from bed to chair, or ability to turn and position self in bed if patient is bedfast.
0 - Able to independently transfer.

o 1 - Able to transfer with minimal human assistance or with use of an assistive device.
o 2 - Able to bear weight and pivot during the transfer process but unable to transfer self.
Page 18 of 33

SOC: 01/02/2016
Episode: 2 -- 03/02/2016 - 04/19/2016
ADLs & IADLs

o 3 - Unable to transfer self and is unable to bear weight or pivot when transferred by another person.
o 4 - Bedfast, unable to transfer but is able to turn and position self in bed
o 5 - Bedfast, unable to transfer but is unable to turn and position self
Ambulation/Locomotion: Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of
surfaces.
0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings(i.e. needs no human assistance
or assistive device).
o 1 - With the use of one handed device(e.g. cane, single crutch, hemi-walker),able to independently walk on even and uneven surfaces and
negotiate stairs with or without railings.
o 2 - Requires use of a two-handed device(e.g. walker or crutches) to walk alone on a level surface and/or requires human supervision or
assistance to negotiate stairs or steps or uneven surfaces
o 3 - Able to Walk only with the supervision or assistance of another person at all times.
o 4 - Chairfast, unable to ambulate but is able to wheel self independently.
o 5 - Chairfast, unable to ambulate and is unable to wheel self.
o 6 - Bedfast, unable to ambulate or be up in a chair.
Feeding or Eating: Current ability to feed self meals and snacks safely. Note: This refers only to the process of eating, chewing and swallowing,
not preparing the food to be eaten.
0 - Able to independently feed self.

o 1 - Able to feed self independently but requires: (a) meal set-up, OR (b) intermittent assistance or supervision from another person, OR (c) a
liquid, pureed or ground meat diet.
o 2 - Unable to feed self and must be assisted or supervised throughout the meal/snack.
o 3 - Able to take in nutrients orally and receives supplemental nutrients through a nasogastric tube or gastrostomy.
o 4 - Unable to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.
o 5 - Unable to take nutrients orally or by tube feeding
Current Ability to Plan and Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely:
0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals, OR (b) Is physically, cognitively, and mentally
able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care
admission).
o 1 - Unable to prepare light meals on a regular basis due to physical, cognitive, or mental limitations
o 2 - Unable to prepare any light meals or reheat any delivered meals
Ability to Use Telephone: Current ability to answer the phone safely, including dialing numbers, and effectively using the telephone to communicate.
0 - Able to dial numbers and answer calls appropriately and as desired.

o 1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.
o 2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.
o 3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.
o 4 - Unable to answer the telephone at all but can listen if assisted with equipment.
o 5 - Totally unable to use the telephone
o NA - Patient does not have a telephone.
Page 19 of 33

SOC: 01/02/2016
Episode: 2 -- 03/02/2016 - 04/19/2016
Medication
(M2004)
Medication Intervention: If there were any clinically significant medication issues at the time of, or at any time since the previous OASIS assessment,
was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues,
0 - No.
o 1 - Yes.
o 2 - No Clinically significant medication issues identified since the previous OASIS assessment.
(M2015)
Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency, staff or other
health care provider to monitor the effectiveness of drug therapy, drug reactions, side effects and how and when to report problems that may occur ?
0 - No.
o 1 - Yes.
o 2 - Patient not taking any drug.
(M2020)
Management of Oral Medications: Patient's current ability to prepare and take all oral medications reliably and safely, including administration of the
correct dosage at the appropriate times/intervals. Excludes injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness.)
0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.
o 1 - Able to take medication(s) at the correct times(if a. Individual dosages prepared in advance by another person or b. another person develops a
drug diary or chart).
o 2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times.
o 3 - Unable to take medication unless administered by another person.
o NA - No oral medications prescribed.
(M2030)
Management of Injectable Medications: Patient's current ability to prepare and take all prescribed injectable medications reliably and safely, including
administration of correct dosage at the appropriate times/intervals. Excludes IV medications.
0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times
o 1 - Able to take injectable medication(s) at the correct times(if a. Individual syringes are prepared in advance by another person or b. another person
develops a drug diary or chart)
o 2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection
o 3 - Unable to take injectable medication unless administered by another person
o NA - No injectable medications prescribed
Infusion Therapy/Site Care
o N/A
No problem Found
o Peripheral Line
o Catheter
o Central Line
Purpose of Intravenous Access
o Antibiotic Therapy
o Chemotherapy
o Hydration
o Lab Draws
o Pain Control
o Parenteral Nutrition
o Maintain Venous Access
o Other:
Type
o PICC
o PASV
o Groshong
o Hickman
o Port-a-cath
o Peripheral/Heplock
o Catheter(size):
o Extension Tubing
o Other Type/Brand:
Lumens
o Single
o Double
o Triple
Pump
o Curlin
o Cadd
o Other:
Size/Gauge/Length:
Insertion Site:
Date:
Flush Solution/Frequency:
Site Assessment
o No Problems
o Reddened
o Edema
o Drainage
o Catheter loose
o Dressing change needed
Catheter length: cm/in
Arm Circumference(if applicable): cm/in
Page 20 of 33

SOC: 01/02/2016
Episode: 2 -- 03/02/2016 - 04/19/2016
Medication
External catheter length:
Dressing Change Freq:
Injection Cap Change Freq(Specify):
Performed By: o Patient o RN o Caregiver
Notes:
Infusion Care Provided during visit
o Venipuncture for IV start
o Sterile
o Clean
o Other:
o IV Care Provided
Location:
Device Used:
Attempts:
o Site Dressing Change(describe):

o Extension Tubing/Cap Change(describe):
o Infusion Start/Flush(describe):
Page 21 of 33

SOC: 01/02/2016
Episode: 2 -- 03/02/2016 - 04/19/2016
Care Management
(M2102) (only one box in each row)
Types and Sources of Assistance: Determine the ability and willingness of non-agency caregivers (such as family members, friends, or
privately paid caregivers) to provide assistance for the following activities, if assistance is needed. Excludes all care by your agency staff.
Type of Assistance
No assistance
needed
-patient is
independent or
does not have
needs in this
area
Non-agency
caregiver(s)
currently
provide
assistance
Non-agency
caregiver(s)
need training/
supportive
services to
provide
assistance
Non-agency
caregiver(s) are not
likely to provide
assistance OR it is
unclear if they will
provide assistance
Assistance
needed, but no
non-agency
caregiver(s)
available
a)ADL assistance (e.g., transfer/

ambulation, bathing, dressing,
toileting, eating/feeding)
o1
o2
o3
o4
b)IADL assistance (e.g., meals,

housekeeping, laundry,
telephone, shopping, finances)
o1
o2
o3
o4
c)Medication administration (e.g.,

oral, inhaled or injectable)
o1
o2
o3
o4
d)Medical procedures/treatments
(e.g., changing wound dressing)
o1
o2
o3
o4
e)Management of Equipment
(includes oxygen, IV/infusion
equipment, enteral/ parenteral
nutrition, ventilator therapy
o1
o2
o3
o4
f) Supervision and safety (e.g., due

to cognitive impairment)
o1
o2
o3
o4
g)Advocacy or facilitation of
patient's participation in
appropriate medical care
(includes transportation to or
o1
o2
o3
o4
Page 22 of 33

SOC: 01/02/2016
Episode: 2 -- 03/02/2016 - 04/19/2016
Emergent Care
Emergent Care: At the time of or at any time since the last time OASIS data were collected, has the patient utilized a hospital emergency
department (includes holding/observation status) ?
0 - No [Go To M2400]
o 1 - Yes, used hospital emergency department WITHOUT hospital admission
o 2 - Yes, used hospital emergency department WITH hospital admission
o UK - Unknown [Go To M2400]
(M2310) Mark all that apply
Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization) ?
o 1 - Improper medication administration, medication side effects, toxicity, anaphylaxis

o 2 - Injury caused by fall
o 3 - Respiratory infection (e.g., pneumonia, bronchitis)
o 4 - Other respiratory problem
o 5 - Heart failure (e.g., fluid overload)
o 6 - Cardiac dysrhythmia (irregular heartbeat)
o 7 - Myocardial infarction or chest pain
o 8 - Other heart disease
o 9 - Stroke (CVA) or TIA
o 10 - Hypo/Hyperglycemia, diabetes out of control
o 11 - GI bleeding, obstruction, constipation, impaction
o 12 - Dehydration, malnutrition
o 13 - Urinary tract infection
o 14 - IV catheter-related infection or complication
o 15 - Wound infection or deterioration
o 16 - Uncontrolled pain
o 17 - Acute mental/behavioral health problem
o 18 - Deep vein thrombosis, pulmonary embolus
o 19 - Other than above reasons
o 20 - Reason unknown
Page 23 of 33

SOC: 01/02/2016
Episode: 2 -- 03/02/2016 - 04/19/2016
Discharge
(M2400) (Check only one box in each row )
Intervention Synopsis: At the time of or at any time since the previous OASIS assessment, were the following interventions BOTH included in
the physician-ordered plan of care AND implemented?
Plan / Intervention
No
Yes
Not Applicable
a) Diabetic foot care including monitoring for the

presence of skin lesions on the lower extremities
and patient/caregiver education on proper foot care
o1
o 2-NA
Patient is not diabetic or is missing lower legs due to

congenitial or acquired condition (bilateral amputee).
b) Falls prevention interventions
o1
o 2-NA
Every standardized, validated multi-factor fall risk assessment

conducted at or since the last OASIS assessment indicates the
patient has no risk for falls.
c) Depression intervention(s) such as medication,

referral for other treatment, or a monitoring plan for
current treatment
o1
o 2-NA
Patient has no diagnosis of depression AND every

standardized , validated depression screening conducted
at or since the last OASIS assessment indicates the
patient has: 1) no symptoms of depression; or 2) has
some symptoms of depression but does not meet criteria
for further evaluation of depression based on screening
tool used.
d) Intervention(s) to monitor and mitigate pain
o1
o 2-NA
Every standardized, validated pain assessment conducted

at or since the last OASIS assessment indicates the patient
has no pain.
e) Intervention(s) to prevent pressure ulcers
o1
o 2-NA
Every standardized, validated pressure ulcer risk assessment

conducted at or since the last OASIS assessment indicates the
patient is not at risk of developing pressure ulcers.
f) Pressure ulcer treatment based on principles of

moist wound healing
o1
o 2-NA
Patient has no pressure ulcers OR has no pressure ulcers for

which moist wound healing is indicated.
(M2410)
To which Inpatient Facility has the patient been admitted ?

o 1 - Hospital [Go to M2430]
o 2 - Rehabilitation facility [Go to M0903]
o 3 - Nursing home [Go to M0903]
o 4 - Hospice [Go to M0903]
NA - No inpatient facility admission [Omit "NA" option on TRN]
(M2420) ( Choose only one answer )
Discharge Disposition: Where is the patient after discharge from your agency ?
o 1 - Patient remained in the community(without formal assistive services)

o 2 - Patient remained in the community (with formal assistive services)
o 3 - Patient transferred to a non-institutional hospice
o 4 - Unknown because patient moved to a geographic location not served by this agency
UK - Other unknown
(M0903)
Date of Last (Most Recent) Home Visit: 04/16/2016
(M0906)
Discharge/Transfer/Death Date: Enter the date of the discharge, transfer, or death (at home) of the patient.
04/19/2016
Page 24 of 33

SOC: 01/02/2016
Episode: 2 -- 03/02/2016 - 04/19/2016
DISCHARGE SUMMARY
Physician: pcp, hemanth
Phone: (222) 222-2222
Fax: (243) 543-5467
Reason for Admission (describe condition)

asfasf
Services Provided During Patient's Admission
o sn
o PT
o ST
o OT
o Other:
SOC Date: 01/02/2016
Last Visit: 04/16/2016
Discharge Date: 04/19/2016
Summary of Care (include progress toward goal and patient understanding of disease management)
Temperature:34-34
Pulse:34-34
Respiration:34-34
Blood Pressure
Systolic:34-34
Diastolic:3-34
Medication Status
o No problem identified during medication review
o Potential adverse effects/drug interactions

o Ineffective drug therapy
o Significant side effects
o Significant drug interactions
o Duplicate drug therapy
o Non-compliance with drug therapy
o No change
o Other:
Reason for Discharge
Admitted to Hospital
o Death
o Lack of Funds
o No Further Home Health Care Needed
o Patient Refused Service
o Transferred to Another HHA
o Transferred to Hospice
Admitted to Hospital
o Death
o Lack of Funds
o No Further Home Health Care Needed
o Patient Refused Service
o Transferred to Another HHA
o Transferred to Hospice
o Prolonged On-Hold Status
o Goals Met
o Admitted to SN / IC Facility
o Family / Friends Assumed Responsiblity
o Lack of Progress
o Patient Moved out of Area
o Physician Request
o Transferred to Home Care (Personal Care)
o Transferred to Outpatient Rehabilitation
o Admitted to SN / IC Facility
o Family / Friends Assumed Responsiblity
o Lack of Progress
o Patient Moved out of Area
o Physician Request
o Transferred to Home Care (Personal Care)
o Transferred to Outpatient Rehabilitation
o Reached Maximum Potential
o Agency/Organization decision Explain:

o Other(specify):
Discharge Reason Billing Code: 01 - Discharged to home for self care (routine discharge)
Discharge Instructions (future follow-up,referrals,etc.)
Reviewed:
o Home safety
o Fall safety
o When to contact physician
o Next appointment physician
o Other(describe):
Written instructions given to patient/caregiver: o Yes o No
Patient/Caregiver demonstrates understanding of instructions: o Yes o No
Page 25 of 33
o Medication safety
o Standard precautions

SOC: 01/02/2016
Episode: 2 -- 03/02/2016 - 04/19/2016
DISCHARGE SUMMARY
Referrals Indicated
o None indicated o Yes(describe below)
Page 26 of 33

SOC: 01/02/2016
Episode: 2 -- 03/02/2016 - 04/19/2016
Assessment Summary
Assessment Summary Note:
saf
Patient / Family Instruction:
asf
Page 27 of 33

SOC: 01/02/2016
Episode: 2 -- 03/02/2016 - 04/19/2016
Care Co-0rdination
Care Co-ordination Notes: sadfasf
Page 28 of 33

SOC: 01/02/2016
Episode: 2 -- 03/02/2016 - 04/19/2016
Discharge Order
Order#: D-4025
Signed By: rn, hemanth - sn On 04/19/2016
Order Description:
asf
Comments :
asf
Page 29 of 33

SOC: 01/02/2016
Episode: 2 -- 03/02/2016 - 04/19/2016
Reconciliation of Visits
Total Schedules: 4
Visit
Date
Clinician
Discipline Job Description
Start Time-End Time
Authorization
03/09/2016
rn, hemanth
sn
09:00 AM - 10:00 AM
-NA-
Approved
03/11/2016
rn, hemanth
sn
09:00 AM - 10:00 AM
-NA-
Approved
03/22/2016
04/19/2016
rn, hemanth
rn, hemanth
sn
sn
09:00 AM - 10:00 AM
09:00 AM - 10:00 AM
-NA-NA-
Approved
Approved
sn -discipline
discharge
adult sn discipline
discharge form
sn-discharge
sn-discharge
Therapy Visits
Date
Total Schedules:
Clinician
Discipline Job Description
Page 30 of 33
Start Time-End Time
Authorization
Visit

SOC: 01/02/2016
Episode: 2 -- 03/02/2016 - 04/19/2016
Outcome Analysis
Reviewed
Outcome
Not Compared
Mcode
M1800 - Grooming(Current)
From
-
M1810 - Current Ability to Dress Upper

Body
M1820 - Current Ability to Dress Lower

Body
M1830 - Bathing(Current)
M1840 - Toilet Transferring(Current)
M1850 - Transferring(Current)
M1860 - Ambulation/Locomotion(Current)
M1870 - Feeding or Eating(Current)
M1880 - Current Ability to Plan and

Prepare Light Meals
M1890 - Ability to Use Telephone(Current)
M2020 - Management of Oral Medications
M1600 - Has this patient been treated for

a Urinary Tract Infection in the past 14
days ?
M1615 - When does Urinary Incontinence
occur ?
M1620 - Bowel Incontinence Frequency
To
0 - Able to groom self unaided,
with or without the use of
assistive devices or adapted
methods.
0 - Able to get clothes out of
closets and drawers, put them on
and remove them from the upper
body without assistance.
0 - Able to obtain,put on,and
remove clothing and shoes
without assistance.
0 - Able to bathe self in shower or
tub independently, including
getting in and out of tub/shower.
0 - Able to get to and from the
toilet and transfer independently
with or without a device.
0 - Able to independently transfer.
0 - Able to independently walk on
even and uneven surfaces and
negotiate stairs with or without
railings(i.e needs no human
assistance or assistive device).
0 - Able to independently feed
self.
0 - (a) Able to independently plan
and prepare all light meals for
self or reheat delivered meals,
OR (b) Is physically, cognitively,
and mentally able to prepare light
meals on a regular basis but has
not routinely performed light meal
preparation in the past (i.e., prior
to this home care admission).
0 - Able to dial numbers and
answer calls appropriately and as
desired.
0 - Able to independently take the
correct oral medication(s) and
proper dosage(s) at the correct
times.
0 - No
Not Compared
Not Compared
M1710 - When Confused (Reported or

Observed Within the Last 14 Days)
M1700 - Cognitive Functioning: Patient's
current (day of assessment) level of
alertness, orientation, comprehension,
concentration, and immediate memory for
0 - Very rarely or never has bowel

incontinence.
0 - Never.
0 - Alert/Oriented, able to focus
and shift attention, comprehends
and recalls task directions
independently.
Not Compared
Page 31 of 33
Not Compared
Not Compared
Not Compared
Not Compared
Not Compared
Not Compared
Not Compared
Not Compared
Not Compared
Not Compared
Not Compared
Not Compared

SOC: 01/02/2016
Episode: 2 -- 03/02/2016 - 04/19/2016
Outcome Analysis
Mcode
simple commands.
M1720 - When Anxious (Reported or
Observed Within the Last 14 Days):
M1745 - Frequency of Disruptive Behavior
Symptoms (Reported or Observed)
M1230 - Speech and Oral (Verbal)
Expression of Language (in patient's own
language).
From
To
Outcome
0 - None of the time.
Not Compared
0 - Never.
Not Compared
Not Compared
M1242 - Frequency of Pain Interfering

Pain Assessment with patient's activity or
movement
M1340 - Does this patient have a Surgical
Wound ?
M1342 - Status of Most Problematic
(Observable) Surgical Wound
M1400 - When is the patient dyspneic or
noticeably Short of Breath ?
M1610 - Urinary Incontinence or Urinary
Catheter Presence
0 - Express complex ideas,

feelings and needs clearly,
completely, and easily in all
situations with no observable
impairment.
0 - Patient has no pain.
0 - No
Not Compared
Not Compared
0 - Patient is not short of breath
Not Compared
0 - No incontinence or catheter
(includes anuria or ostomy for
urinary drainage)
Not Compared
Page 32 of 33
Not Compared

SOC: 01/02/2016
Episode: 2 -- 03/02/2016 - 04/19/2016
Interventions
Interventions
SN INTERVENTIONS
Performed
No
Clinician Signature: hemanth rn - sn
Reviewed
Completed
No
Date:04/19/2016
Page 33 of 33

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hemanth

branch1 address, Schenectady, NY 12345

OASIS - Discharge from Agency

Episode: 2 -- 03/02/2016 - 04/19/2016

Visit Date: 04/19/2016

Check In Time: 09:00 AM

Check Out Time: 10:00 AM

(M0010) CMS Certification Number:

(M0063) Medicare Number: 1234567890 o NA

(M0018) NPI for the Attending Physician: 1233333423

(M0064) Social Security Number: UK

(M0030) Start of Care Date: 01/02/2016

(M0069) Gender: Male

(M0032) Resumption of Care Date:

Clinical Record Items

(M0090) Date Assessment Completed: 04/21/2016

o 1 - Start of Care - further visits planned

OASIS - Discharge from Agency

Episode: 2 -- 03/02/2016 - 04/19/2016

Visit Date: 04/19/2016

Check In Time: 09:00 AM

Check Out Time: 10:00 AM

Patient History & Diagnosis

(M1046) (Check one)

o 1 - Yes [Go to M1500 at TRN; Go to M1230 at DC ]

(M1056) Reason Pneumococcal Vaccine not received:

1 - Offered and declined

Patient Herpes Zoster (Shingles) vaccine status

Reason for contact: asf

o Oral o Axillary o Rectal o Tympanic o Temporal Artery

O2 Sat less than(<)

OASIS - Discharge from Agency

Episode: 2 -- 03/02/2016 - 04/19/2016

Visit Date: 04/19/2016

Check In Time: 09:00 AM

Check Out Time: 10:00 AM

Patient History & Diagnosis

Primary Reason for Home Health

OASIS - Discharge from Agency

Episode: 2 -- 03/02/2016 - 04/19/2016

Visit Date: 04/19/2016

Check In Time: 09:00 AM

Check Out Time: 10:00 AM

o N/A o No Problem Found

o N/A o No Problem Found

o N/A o No Problem Found

o N/A o No Problem Found

o N/A o No Problem Found

o N/A o No Problem Found

0 - Patient has no pain

o 3 - Daily, but not constantly

OASIS - Discharge from Agency

Episode: 2 -- 03/02/2016 - 04/19/2016

Visit Date: 04/19/2016

Check In Time: 09:00 AM

Check Out Time: 10:00 AM

Number Currently Present

Stage description - unhealed pressure ulcers

OASIS - Discharge from Agency

Episode: 2 -- 03/02/2016 - 04/19/2016

Visit Date: 04/19/2016

Check In Time: 09:00 AM

Check Out Time: 10:00 AM