OASIS and coding are completed through different processes, but both describe the same patient. When they are aligned, the record more accurately reflects the patient’s condition, functional limitations, and need for skilled home health services. When they are not, inconsistencies can lead to questions and rework.
Start With the Patient
Documentation should begin with the patient’s actual condition—not with a code or an attempt to make an OASIS response fit a diagnosis.
For example, a patient may be admitted after a fall but receive skilled care primarily because of weakness, impaired balance, a fracture, or a neurological condition. The fall may explain why the patient was hospitalized, but it may not be the condition chiefly responsible for the current need for home health services.
The OASIS assessment, diagnoses, and plan of care should reflect the patient’s current condition and care needs.
Connect the Details
The different parts of the record do not need to use the same words, but they should support one another.
For example:
- Muscle weakness should be supported by documentation describing how the weakness affects the patient.
- Difficulty in walking should be consistent with the patient’s documented mobility limitations.
- Balance impairment should be supported by clinical findings and functional limitations.
If a patient is documented as requiring substantial assistance with mobility but is also described as independently ambulating throughout the home, the discrepancy should be reviewed and clarified.
Be Specific
Small details can affect how accurately a patient’s condition is represented.
Compare:
- “Patient has pain” with pain documented by location, severity, triggers, and impact on function.
- “Patient is weak” with documentation identifying the affected areas, functional impact, and assistance required.
- “History of stroke” with documentation of current residual deficits, such as hemiparesis or impaired coordination.
- “Wound present” with documentation of its location, characteristics, measurements, and clinical cause.
Specific documentation provides better support for both OASIS responses and coding decisions.
Understand the Different Roles of OASIS and Coding
OASIS and coding are not meant to duplicate one another.
For example, a clinical assessment of a pressure ulcer may document its location, measurements, drainage, appearance, and stage. Coding requires documentation supporting the appropriate diagnosis, including the underlying condition and etiology when applicable.
Each part of the record serves a different purpose. The important thing is that the information is consistent and supports the patient’s overall condition and care needs.
Review the Whole Record
No single diagnosis, OASIS response, or clinical note provides the complete picture.
A patient with heart failure may also have shortness of breath, fatigue, edema, and reduced endurance. A patient with a hip fracture may have pain, weakness, and impaired mobility. These details may appear in different parts of the record.
This is where quality assurance (QA) plays an important role. By reviewing the record as a whole, QA can help identify inconsistencies between the OASIS, diagnoses, and plan of care. QA can also help identify missing details or documentation that may need clarification.
A comprehensive review helps ensure that the different parts of the record accurately reflect the patient’s condition and support the need for skilled care.
