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Total # of Questions: 55

Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment] [93058-6]

Date Done

Time Done

Where Done

Comment

Name

Value

Units

CLINICAL RECORD ITEMS [86245-8]

Discipline of Person Completing Assessment [46500-5]

Date Assessment Completed [46501-3]

This Assessment is Currently Being Completed for the Following Reason [57200-8]

Episode Timing: Is the Medicare home health payment episode for which this assessment will define a case mix group an "early" episode or a "later" episode in the patient's current sequence of adjacent Medicare home health payment episodes? [57203-2]

PATIENT HISTORY AND DIAGNOSES [93056-0]

Diagnoses and Symptom Control [88488-2]

Primary Diagnosis [88489-0]

Primary Diagnosis: ICD-10-code [86255-7]

Primary Diagnosis Symptom Control Rating [85920-7]

Other Diagnoses [88490-8]

Other Diagnoses: ICD-10-CM [81885-6]

Other Diagnoses Symptom Control Rating [85920-7]

Therapies the patient receives at home [46466-9]

Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? [57319-6]

SENSORY STATUS [88492-4]

Vision (with corrective lenses if the patient usually wears them) [57215-6]

Frequency of Pain Interfering with patient's activity or movement [57220-6]

INTEGUMENTARY STATUS [88463-5]

Does this patient have at least one Unhealed Pressure Ulcer/Injury at Stage 2 or Higher or designated as Unstageable? [85918-1]

Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage [88494-0]

Number of Stage 2 pressure ulcers [55124-2]

Number of Stage 3 pressure ulcers [55125-9]

Number of Stage 4 pressure ulcers [55126-7]

Number of unstageable pressure ulcers/injuries due to non-removable dressing/device [54893-3]

Number of unstageable pressure ulcers/injuries due to coverage of wound bed by slough and/or eschar [54946-9]

Number of unstageable pressure injuries presenting as deep tissue injury [54950-1]

Current Number of Stage 1 Pressure Injuries [46536-9]

Stage of Most Problematic Unhealed Pressure Ulcer/Injury that is Stageable [57231-3]

Does this patient have a Stasis Ulcer? [57232-1]

Current Number of Stasis Ulcer(s) that are Observable [57233-9]

Status of Most Problematic Stasis Ulcer that is Observable [57234-7]

Does this patient have a Surgical Wound? [57235-4]

Status of Most Problematic Surgical Wound that is Observable [57236-2]

RESPIRATORY STATUS [86249-0]

When is the patient dyspneic or noticeably Short of Breath? [57237-0]

ELIMINATION STATUS [86250-8]

Urinary Incontinence or Urinary Catheter Presence [46553-4]

Bowel Incontinence Frequency [46587-2]

Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay; or b) necessitated a change in medical or treatment regimen? [86471-0]

ADL/IADLs [93057-8]

Grooming: Current ability to tend safely to personal hygiene needs (specifically: washing face and hands, hair care, shaving or make up, teeth or denture care, or fingernail care). [46595-5]

Current Ability to Dress Upper Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps. [46597-1]

Current Ability to Dress Lower Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes. [46599-7]

Bathing: Current ability to wash entire body safely. Excludes grooming (washing face, washing hands, and shampooing hair). [57243-8]

Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode. [57244-6]

Transferring: Current ability to move safely from bed to chair, or ability to turn and position self in bed if patient is bedfast. [57246-1]

Ambulation/Locomotion: Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces. [57247-9]

MEDICATIONS [86252-4]

Management of Injectable Medications: Patient's current ability to prepare and take all prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals [57284-2]

THERAPY NEED AND PLAN OF CARE [88503-8]

Therapy need: Number of therapy visits indicated (total of physical, occupational and speech-language pathology combined) [57268-5]

Functional Abilities and Goals [88484-1]

Self-Care - Follow-up Performance [88485-8]

Eating [95019-6]

Oral hygiene [95018-8]

Toileting hygiene [95017-0]

Mobility - Follow-up Perfomance [88486-6]

Roll left and right [95011-3]

Sit to lying [95010-5]

Lying to sitting on side of bed [95009-7]

Sit to stand [95008-9]

Chair/bed-to-chair transfer [95007-1]

Toilet transfer [95006-3]

Walk 10 feet [95004-8]

Walk 50 feet with two turns [95003-0]

Walking 10 feet on uneven surfaces [95001-4]

1 step (curb) [95000-6]

4 steps [94999-0]

Does the patient use a wheelchair and/or scooter? [95738-1]

Wheel 50 feet with two turns [94992-5]

PLEASE WAIT