Quality Assurance (QA) review for the OASIS is essential to ensure accuracy, compliance, and optimal reimbursement in home health. However, without the right strategy in place, QA reviews can become time-consuming, inconsistent, and burdensome for clinicians.
By implementing best practices, the review process can be made both efficient and effective.
Standardization of the Review Process
A consistent checklist or structured protocol should be created that covers all critical OASIS items, including demographics, clinical assessments, functional scores, and coding accuracy. Establishing a protocol ensures that no area is overlooked, maintains consistency in review standards, and speeds up the review process.
Emphasis on High-Risk Items
Items most likely to impact outcomes, quality measures, and reimbursement—such as GG functional items, comorbidity coding, and hospitalization risk factors—should receive greater attention during QA review. Focusing on these high-impact areas ensures compliance, process efficiency, and minimizes the need for repeated reviews.
Leveraging Technology
EHR tools and dashboards should be utilized to flag missing or inconsistent data. Automated alerts for incomplete fields, conflicting responses, or high-risk scenarios—such as those generated by third-party OASIS scrubber integrations—can help direct reviewers to the areas that need the most attention. The sticky notes feature in most EHRs is also useful for quickly pinpointing the exact sections that need correction.
Optimal Timing
Knowing the optimum time to conduct QA review for the OASIS and the Plan of Care (POC) is very important for accuracy and process efficiency. QA review for the OASIS is best conducted after completing diagnosis coding. Performing the review at this point allows the QA team to validate whether the OASIS documentation fully supports the selected codes. Any discrepancies between assessment findings and coded diagnoses can be identified and clarified before further processes are completed. This step ensures clinical and coding alignment, supports compliance, and prevents unnecessary re-coding later.
Conducting the QA review before the POC is generated provides an opportunity to correct documentation gaps and ensure that identified problems, functional levels, and risk factors are accurately reflected. When the OASIS data and diagnoses are verified before POC generation,, the POC can be created based on accurate, complete, and clinically sound information—resulting in better coordination, fewer revisions, and improved overall workflow efficiency.
Clear Feedback, Rationale, and Communication
QA feedback should be communicated clearly and promptly to the clinical team. Corrective recommendations should include the rationale behind them, so clinicians can understand the reasoning and apply it to future charting. This approach promotes ongoing learning and helps improve charting skills over the long term.
Balanced Correction Approach
Certain minor or administrative corrections may be completed directly by the QA team to prevent clinicians from receiving an overwhelming volume of feedback and to save time. However, this should be done selectively and without removing the opportunity for clinicians to learn. For areas with clinical or assessment significance, clinicians should still be guided to make their own corrections, supported by clear explanations and rationale to reinforce learning.
Tracking Trends and Providing Feedback
Common errors or recurring trends across cases should be monitored to identify areas for staff education and process improvement. Regular feedback sessions can prevent repeated mistakes and improve overall OASIS quality.
By following these best practices, OASIS QA reviews can be streamlined, errors can be reduced, and accurate, compliant documentation reflecting patient care can be ensured—all while promoting clinician development and maintaining process efficiency.
