The home health Discharge OASIS plays a crucial role in agencies’ performance scores under Value-Based Purchasing and quality reporting (star ratings) programs, as well as in assessing the impact of patient care services on overall patient recovery.
Here are practical tips to ensure accuracy in your Discharge OASIS documentation:
1. Use OASIS “Follow-Up” to Clarify Changes
During the care episode, if a patient experiences significant changes in their condition—such as hospitalization or severe illness—be sure to accurately complete the OASIS Follow-Up to document these changes. This will create a clear narrative that highlights the impact of these significant changes on the patient’s outcomes and discharge status.
2. Document the Final Visit Thoroughly
On the final visit, assess the patient holistically. Be mindful of capturing every improvement or decline in functional abilities. Thorough documentation not only justifies the patient’s discharge status but can improve outcome measures like the improvement in ambulation or medication management, which are key for HHVBP adjustments.
3. Cross-Check Assessments With the latest OASIS Data
To ensure accuracy and consistency, review the patient’s latest OASIS data (SOC/ REC/ROC/Follow-up) and compare them with their discharge status. Any significant improvement or decline should be clinically supported. Inconsistencies between the patient status between the last OASIS assessment and discharge data can lead to audits and affect your HHVBP score negatively.
4. Ensure Accurate Reporting on Wounds and Infections
Pay close attention to the status of wounds and infections. Since wound care is a common trigger for rehospitalizations, the correct documentation of healing rates and infection status impacts both star ratings and HHVBP measures. Reassess all wounds to avoid discrepancies between the wound status at the start of the care episode and at discharge.
5. Encourage Real-Time OASIS Entry
Whenever possible, encourage clinicians to complete OASIS documentation in real-time rather than after the visit. This reduces the likelihood of errors or omissions. Real-time entry also provides a more accurate reflection of the patient’s status, impacting clinical outcomes measures and, subsequently, your agency’s HHVBP adjustments.
6. Ensure Accurate Functional Assessment
Beginning in 2025, the HHVBP will include a new Discharge Function Score, an OASIS-based outcome measure calculated from GG functional assessment items. This new HHVBP measure focuses on functional improvement at discharge. Scoring GG items accurately helps showcase progress in patient function. Be sure to record any improvements in self-care and mobility, but also document if the patient has maintained a higher functional status during the episode.
The GG items are graded on a scale that requires attention to small details. Ensure the staff understands the nuances between “helper needed” versus “independent” scoring levels. For example, a patient who requires assistance with setting up a task (GG0130A – Eating) is not the same as someone who requires active feeding assistance. Training staff to correctly identify these levels can prevent inaccuracies and boost overall performance on the Discharge Function measure.
Importance of Knowledge and Training
It is vital that clinicians and the QA teams are well-versed in the proper guidelines and standards for OASIS Discharge documentation. Accurate assessment is key to demonstrating patient improvement at discharge (if applicable) and maximizing performance scores on HHVBP and star ratings. Refresher training on discharge documentation can greatly help. A key topic to cover is proper GG item scoring, especially in preparation for the upcoming introduction of the new Discharge Function Score.
