The Transfer OASIS may be shorter than other timepoints, but it plays a critical role for compliance, continuity of care, and quality reporting. Errors in the Transfer OASIS can cause confusion when the patient returns to home health, distort outcome measures, and raise concerns during audits.
Let’s review some best practices to complete the Transfer OASIS with accuracy and foresight.
1. Align Transfer With Discharge Planning
Even though the patient is not being discharged, the Transfer OASIS should reflect a “closing of the loop.” Capture the most recent, reliable data so the receiving facility has a clear picture, and so your team has solid documentation if the patient comes back under your care. Write as if someone unfamiliar with the case will review the chart weeks later.
2. Cross-Check With Recent Documentation
Before finalizing, compare your Transfer OASIS entries with the most recent visit notes, functional status, and medication lists. This is to avoid inconsistencies that can cause issues in audits or create confusion for clinicians handling a Resumption of Care.
3. Think Ahead for Possible Resumption
Many transferred patients return home under your care. Thoroughly capturing their latest status now makes the Resumption OASIS easier and more accurate later.
4. Stay Current on GG Items
It is tempting to carry forward the last functional status, but the GG items at Transfer should reflect the patient’s condition right before transfer. If the patient has declined due to an acute episode, document it accurately so the record reflects a realistic picture.
5. Code M2420 With Care
M2420 (Discharge Disposition at Transfer) is often mis-coded. Base your answer on where the patient is physically going at the time of transfer—not on assumptions about future plans. Double-check hospital status—observation vs. inpatient—before finalizing. This small detail can prevent reporting errors.
6. Add Context With Narrative Notes
OASIS answers alone do not capture the “why.” A brief narrative note describing the reason for transfer, recent changes, and your communication with the facility can be invaluable for both continuity of care and audit protection.
7. Do a Quick Med Review
A full medication reconciliation is not required, but a quick review before transfer is good practice. It ensures consistency and helps the receiving facility start with the right list. Confirm meds during your transfer call/report and document the communication.
8. Document in Real Time
Complete as much of the Transfer OASIS as possible at the bedside or while communicating with the receiving facility. Real-time documentation reduces gaps, avoids guesswork, and keeps the record reliable.
9. Apply targeted QA checks
Because the Transfer OASIS is less common, it’s easy to overlook. In your QA protocol, emphasize reviewing M2420 to ensure the disposition matches the facility status, and checking that GG items reflect the patient’s most recent condition. This further ensures accurate documentation for resumption of care, outcome reporting, and audits.
The Transfer OASIS is critical because it validates where the patient went (M2420), captures their most current functional status (GG items), and provides the clinical snapshot auditors and payers rely on to justify services and outcomes. Inaccurate or vague entries can misrepresent quality data, trigger denials, or create audit vulnerabilities. Accurate, timely documentation at transfer ensures your agency stays aligned with regulatory requirements while protecting future billing and outcome reporting.
