Outcome and Assessment Information Set OASIS-D Guidance Manual Effective January 1, 2019 Centers for Medicare & Medicaid Services PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is x. The time required to complete this information collection is estimated to average 0.3 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. This estimate does not include time for training. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. *****CMS Disclaimer*****Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact Joan Proctor National Coordinator, Home Health Quality Reporting Program Centers for Medicare & Medicaid. OASIS-D Guidance Manual Table of Contents Page CHAPTER 1 — INTRODUCTION 1-1 Preface ....................................................................................................................................................... 1-1 Introduction................................................................................................................................................. 1-1 Revision History ......................................................................................................................................... 1-1 Manual Overview ....................................................................................................................................... 1-2 Why is OASIS Being Revised Now? .......................................................................................................... 1-3 What’s New with the OASIS-D Assessment Instrument? .......................................................................... 1-3 What’s New with the OASIS-D Guidance? ................................................................................................ 1-3 Collecting OASIS Data ............................................................................................................................... 1-3 Eligible Patients ............................................................................................................................. 1-3 Time Points ................................................................................................................................... 1-3 Who Completes OASIS?............................................................................................................... 1-4 Comprehensive Assessment and Plan of Care ............................................................................ 1-5 Process of Care Data Items .......................................................................................................... 1-5 Conventions for Completing OASIS .............................................................................................. 1-6 OASIS Data Accuracy ................................................................................................................................ 1-7 OASIS Data Encoding and Transmission .................................................................................................. 1-8 CHAPTER 2 — OASIS-D: ALL ITEMS AND TIME POINTS VERSIONS 2-1 Introduction................................................................................................................................................. 2-1 All Items...................................................................................................................................................... 2-2 Patient Tracking ...................................................................................................................................... 2-33 Start of Care (SOC) - Admission to Home Health Care ........................................................................... 2-34 Resumption of Care (ROC) after Inpatient Facility Stay .......................................................................... 2-53 Follow-up (FU) – Recertification or Other Follow-up ............................................................................... 2-71 Transfer to Inpatient Facility (TRN) .......................................................................................................... 2-80 Discharge (DC) from Home Health Care, not to an Inpatient Facility ...................................................... 2-85 Death at Home (DAH) .............................................................................................................................. 2-98 CHAPTER 3 — OASIS ITEM GUIDANCE 3-1 Introduction................................................................................................................................................. 3-1 Patient Tracking ........................................................................................................................................3-A OASIS-D Guidance Manual iii Effective 1/1/2019 Centers for Medicare & Medicaid Services OASIS-D Guidance Manual Table of Contents Clinical Record Items ................................................................................................................................3-B Patient History and Diagnoses ................................................................................................................ 3-C Living Arrangements ................................................................................................................................ 3-D Sensory Status ..........................................................................................................................................3-E Integumentary ........................................................................................................................................... 3-F Respiratory Status ................................................................................................................................... 3-G [Intentionally Left Blank] ........................................................................................................................... 3-H Elimination Status ...................................................................................................................................... 3-I Neuro, Emotional, and Behavioral Status ................................................................................................. 3-J ADLs / IADLs ............................................................................................................................................3-K Medications ............................................................................................................................................... 3-L Care Management ................................................................................................................................... 3-M Therapy Need .......................................................................................................................................... 3-N Emergent Care ......................................................................................................................................... 3-O Discharge ..................................................................................................................................................3-P Functional Abilities and Goals .............................................................................................................. 3-GG Health Conditions...................................................................................................................................... 3-J CHAPTER 4 — [Intentionally Left Blank] 4-1 CHAPTER 5 — RESOURCES / LINKS 5-1 Appendices Appendix A: OASIS and the Comprehensive Assessment ........................................................................A-1 Appendix B: OASIS Data Accuracy ...........................................................................................................B-1 Appendix C: OASIS-D Items, Time Points, and Uses .............................................................................. C-1 Appendix D: [Intentionally Left Blank] ....................................................................................................... D-1 Appendix E: Data Reporting Regulations ..................................................................................................E-1 Appendix F: OASIS and Quality Improvement........................................................................................... F-1 Appendix G: Description of Changes from OASIS-C2 to OASIS D .......................................................... G-1 OASIS-D Guidance iv Effective 1/1/2019 Centers for Medicare & Medicaid Services OASIS Guidance Manual Chapter 1 CHAPTER 1 OASIS GUIDANCE MANUAL INTRODUCTION PREFACE