Form CMS-10238 - OASIS Instrument

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid
OMB control numbers for this information are 0938-0760 and 0938-0761. The time required to complete this information collection is estimated to average 0.7 minute per
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have
comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports
Clearance Officer, Baltimore, Maryland 21244-1850.

PRA notice to be updated after PRA review is completed

Home Health Patient Tracking Sheet
(M0010) Agency Medicare Provider Number: __ __ __ __ __ __
(M0014) Branch State: __ __
(M0016) Branch ID Number: __ __ __ __ __ __ __ __ __ __
(M0020) Patient ID Number: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
(M0030) Start of Care Date:

__ __ /__ __ /__ __ __ __
month / day / year

(M0032) Resumption of Care Date: __ __ /__ __ /__ __ __ __
month / day /

 NA - Not Applicable

year

(M0040) Patient Name:
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
(First)
(MI) (Last)

__ __ __
(Suffix)

(M0050) Patient State of Residence: __ __
(M0060) Patient Zip Code: __ __ __ __ __ __ __ __ __
(M0063) Medicare Number: __ __ __ __ __ __ __ __ __ __ __ __
(including suffix)

 NA – No Medicare

(M0064) Social Security Number: __ __ __ - __ __ - __ __ __ __

 UK – Unknown or Not Available

(M0065) Medicaid Number: __ __ __ __ __ __ __ __ __ __ __ __ __ __

 NA – No Medicaid

(M0066) Birth Date:
(M0069) Gender:




1 2 -

__ __ /__ __ /__ __ __ __
month / day / year


Male
Female

(M0072) Primary Referring Physician ID:

 UK – Unknown or Not Available

__ __ __ __ __ __ __ __ __ __
(M0140) Race/Ethnicity (as identified by patient): (Mark all that apply.)

 1
 2
 3
 4
 5
 6
 UK

-

American Indian or Alaska Native
Asian
Black or African-American
Hispanic or Latino
Native Hawaiian or Pacific Islander
White
Unknown

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(M0150) Current Payment Sources for Home Care: (Mark all that apply.)

 0 - None; no charge for current services
 1 - Medicare (traditional fee-for-service)
 2 - Medicare (HMO/managed care/Advantage plan)
 3 - Medicaid (traditional fee-for-service)
 4 - Medicaid (HMO/managed care)
 5 - Workers' compensation
 6 - Title programs (e.g., Title III, V, or XX)
 7 - Other government (e.g., CHAMPUS, VA, etc.)
 8 - Private insurance
 9 - Private HMO/managed care
 10 - Self-pay
 11 - Other (specify)
 UK - Unknown

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Outcome and Assessment Information Set (OASIS-C draft)
Items to be Used at Specific Time Points
Start of Care --------------------------------------------------------------Home Health Patient Tracking Sheet, M0080-M0826,
M1010, M1020, M1030, M1040, M1050, M1060, M1070,
Start of care—further visits planned
M1072, M1080, M1090, M1102, M1110, M1120, M1130,
M1140, M1150, M1160, M1170, M1180
Resumption of Care ----------------------------------------------------M0032, M0080-M0826, M1010, M1020, M1030, M1040,
M1050, M1060, M1070, M1072, M1080, M1090, M1102,
Resumption of care (after inpatient stay)
M1110, M1120, M1130, M1140, M1150, M1160, M1170,
M1180
Follow-Up ----------------------------------------------------------------M0080-M0100, M0110, M0230-M0250, M0390, M0420M0452, M0465-M0490, M0520-M0550, M0652-M0702,
Recertification (follow-up) assessment
M0802, M0826, M1021, M1025, M1031, M1035, M1050,
Other follow-up assessment
M1060, M1065, M1070, M1073, M1085, M1095, M1105,
M1110, M1155, M1160, M1170, M1180
Transfer to an Inpatient Facility-------------------------------------M0080-M0100, M0831-M0855, M0890-M0906, M1021,
Transferred to an inpatient facility—patient not
M1025, M1031, M1035, M1050, M1060, M1065, M1073,
discharged from an agency
M1085, M1095, M1105, M1110, M1155, M1160, M1170,
Transferred to an inpatient facility—patient
M1180
discharged from agency
Discharge from Agency — Not to an Inpatient Facility
Death at home -------------------------------------------------------M0080-M0100, M0906
Discharge from agency --------------------------------------------M0080-M0100, M0250-M0345, M0406-M0540, M0560M0712, M0722-M0772, M0782 - M0802, M0810, M0822M0824, M0831-M0870, M0896, M0900, M0903-M0906,
M1021, M1025, M1031, M1035, M1050, M1060, M1065,
M1070, M1073, M1085, M1095, M1105, M1110, M1120,
M1130, M1140, M1155, M1160, M1170, M1180

CLINICAL RECORD ITEMS
(M0080) Discipline of Person Completing Assessment:

 1-RN

 2-PT

(M0090) Date Assessment Completed:

 3-SLP/ST

 4-OT

__ __ /__ __ /__ __ __ __
month / day / year

(M0100) This Assessment is Currently Being Completed for the Following Reason:
Start/Resumption of Care
 1 – Start of care—further visits planned
 3 – Resumption of care (after inpatient stay)
Follow-Up
 4 – Recertification (follow-up) reassessment [ Go to M0110 ]
 5 – Other follow-up [ Go to M0110 ]
Transfer to an Inpatient Facility
 6 – Transferred to an inpatient facility—patient not discharged from agency [ Go to M0830 ]
 7 – Transferred to an inpatient facility—patient discharged from agency [ Go to M0830 ]
Discharge from Agency — Not to an Inpatient Facility
 8 – Death at home [ Go to M0906 ]
 9 – Discharge from agency [ Go to M0110 ]
(M0102) Date of Referral: Indicate the date this referral for home health services was made.
__ __ /__ __ /__ __ __ __
month / day / year
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(M0104) Date of Physician-ordered Start of Care: If the physician indicated a specific start of care date when the
patient was referred for home health services, record the date specified.
__ __ /__ __ /__ __ __ __
month / day / year



 NA – No specific SOC date ordered by physician.

(M0110) 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?






 1
 2

UK

NA

-

Early
Later
Unknown
Not Applicable: No Medicare case mix group to be defined by this assessment. 

DEMOGRAPHICS AND PATIENT HISTORY
(M0175) From which of the following Inpatient Facilities was the patient discharged during the past 14 days?
(Mark all that apply.)

 1
 2
 3
 4
 5
 NA

-

Hospital
Rehabilitation facility
Skilled nursing facility
Other nursing home
Other (specify)
Patient was not discharged from an inpatient facility [ If NA go to M0200]

(M0180) Inpatient Discharge Date (most recent):
__ __ /__ __ / __ __ __ __
month / day / year


 UK - Unknown

(M0190) List each Inpatient Diagnosis and ICD-9-CM code at the level of highest specificity for only those
conditions treated during an inpatient stay within the last 14 days (no surgical, E-codes, or V-codes):
Inpatient Facility Diagnosis
ICD-9-CM
a.
(__ __ __  __ __)
b.
(__ __ __  __ __)
(M0200) Medical or Treatment Regimen Change Within Past 14 Days: Has this patient experienced a change in
medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional
diagnosis, etc.) within the last 14 days?




0 1 -

No [ If No, go to M0220; if No at Discharge, go to M0250 ]
Yes

(M0210) List the patient's Medical Diagnoses and ICD-9-CM codes at the level of highest specificity for those
conditions requiring changed medical or treatment regimen (no surgical, E-codes, or V-codes):
Changed Medical Regimen Diagnosis
ICD-9-CM
a.
(__ __ __  __ __)
b.
(__ __ __  __ __)
c.
(__ __ __  __ __)
d.
(__ __ __  __ __)

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(M0220) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If
this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the
past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or
treatment regimen. (Mark all that apply.)

 1  2  3  4  5  6  7  NA  UK -

Urinary incontinence
Indwelling/suprapubic catheter
Intractable pain
Impaired decision-making
Disruptive or socially inappropriate behavior
Memory loss to the extent that supervision required
None of the above
No inpatient facility discharge and no change in medical or treatment regimen in past 14 days
Unknown

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(M0230/240/246) Diagnoses, Severity Index, and Payment Diagnoses: List each diagnosis for which the patient
is receiving home care (Column 1) and enter its ICD-9-CM code at the level of highest specificity (no
surgical/procedure codes) (Column 2). Rate each condition (Column 2) using the severity index. (Choose one value
that represents the most severe rating appropriate for each diagnosis.) V codes (for M0230 or M0240) or E codes
(for M0240 only) may be used. ICD-9-CM sequencing requirements must be followed if multiple coding is indicated
for any diagnoses. If a V code is reported in place of a case mix diagnosis, then optional item M0246 Payment
Diagnoses (Columns 3 and 4) may be completed. A case mix diagnosis is a diagnosis that determines the Medicare
PPS case mix group.
Code each row according to the following directions for each column:
Column 1:
Enter the description of the diagnosis.
Column 2:
Enter the ICD-9-CM code for the diagnosis described in Column 1;
Rate the severity of the condition listed in Column 1 using the following scale:
0 - Asymptomatic, no treatment needed at this time
1 - Symptoms well controlled with current therapy
2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring
3 - Symptoms poorly controlled; patient needs frequent adjustment in treatment and dose monitoring
4 - Symptoms poorly controlled; history of re-hospitalizations
Column 3:
(OPTIONAL) If a V code reported in any row in Column 2 is reported in place of a case mix diagnosis,
list the appropriate case mix diagnosis (the description and the ICD-9-CM code) in the same row in Column 3.
Otherwise, leave Column 3 blank in that row.
Column 4:
(OPTIONAL) If a V code in Column 2 is reported in place of a case mix diagnosis that requires multiple
diagnosis codes under ICD-9-CM coding guidelines, enter the diagnosis descriptions and the ICD-9-CM codes in
the same row in Columns 3 and 4. For example, if the case mix diagnosis is a manifestation code, record the
diagnosis description and ICD-9-CM code for the underlying condition in Column 3 of that row and the diagnosis
description and ICD-9-CM code for the manifestation in Column 4 of that row. Otherwise, leave Column 4 blank
in that row.
(M0230) Primary Diagnosis & (M0240) Other Diagnoses
Column 1

Description
(M0230) Primary Diagnosis
a.

(M0240) Other Diagnoses
b.

(M0246) Case Mix Diagnoses (OPTIONAL)

Column 2

Column 3

ICD-9-CM and severity
rating for each condition

Complete only if a V code in
Column 2 is reported in
place of a case mix
diagnosis.

Column 4
Complete only if the V code
in Column 2 is reported in
place of a case mix
diagnosis that is a multiple
coding situation (e.g., a
manifestation code).

ICD-9-CM /
Severity Rating

Description/
ICD-9-CM

Description/
ICD-9-CM

(V or E codes NOT allowed)

(V or E codes NOT allowed)

a.

a.

(V codes are allowed)
a. ( __ __ __ ● __ __ )

0 1 2 3 4

(__ __ __  __ __ )

(__ __ __  __ __ )

(V or E codes are allowed)

(V or E codes NOT allowed)

(V or E codes NOT allowed)

b.

b.

b. ( __ __ __ __  __ __ )

0 1 2 3 4
c.

c. ( __ __ __ __  __ __ )

(__ __ __  __ __ )
c.

0 1 2 3 4
d.

d. ( __ __ __ __  __ __ )

e. ( __ __ __ __  __ __ )

d.

f. ( __ __ __ __  __ __ )

0 1 2 3 4
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(__ __ __  __ __ )
d.

(__ __ __  __ __ )
e.

0 1 2 3 4
f.

c.
(__ __ __  __ __ )

0 1 2 3 4
e.

(__ __ __  __ __ )

(__ __ __  __ __ )
e.

(__ __ __  __ __ )
f.

(__ __ __  __ __ )
f.

(__ __ __  __ __ )

(__ __ __  __ __ )

Centers for Medicare & Medicaid Services

(M0250) Therapies the patient receives at home: (Mark all that apply.)





1 2 3 -



4 -

(M0275)










Intravenous or infusion therapy (excludes TPN)
Parenteral nutrition (TPN or lipids)
Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the
alimentary canal)
None of the above

Frailty Indicators: Which of the following signs or symptoms characterize this patient as at risk for major
decline or hospitalization? (Mark all that apply.)
1
2
3
4
5
6
7
8

-

Unstable vital signs
Debilitating pain
Recent change in mental status
Recent functional decline
Multiple hospitalizations (>1) in the past 12 months
History of falls (2 or more falls - or any fall with an injury - in the past year)
Other
None of the above

(M0285) Stability Prognosis: Which description best fits the patient’s overall status? [check one]





0 -



1 -



2 -

 3  UK (M0291)

Risk Factors characterizing this patient: (Mark all that apply.)

 1
 2
 3
 4
 5
 UK
(M1010)

The patient is stable with no heightened risk for serious complications and death (beyond those
typical of the patient’s age).
The patient is temporarily facing high health risks but is likely to return to being stable without
heightened risk for serious complications and death (beyond those typical of the patient’s age).
The patient is likely to remain in fragile health and have ongoing high risks of serious
complications and death.
The patient has serious progressive conditions that could lead to death within a year.
The patient’s situation is unknown or unclear.

-

Smoking
Obesity
Alcohol dependency
Drug dependency
None of the above
Unknown

Urgent/Emergency Contact Information: Was the patient or caregiver provided patient-specific verbal
and written instructions during the first visit regarding when and how to contact the HOME HEALTH
AGENCY for urgent health-related problems during the day and after hours, and when to call 911 for a
medical emergency?

 0 - No
 1 - Yes
(M1020) Influenza Vaccine: Has the patient received an influenza vaccination during this year's recommended
time period?

 0  1  NA  UK -

No
Yes
Does not apply. SOC/ROC date is not within time period.
Unknown

(M1021) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency during this year's
recommended time period?
0 No (Complete M1025)
1 Yes (Skip M1025)
 NA - Does not apply because entire care episode is outside this year's recommended time period.
(Skip M1025)

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(M1025) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your
agency, state reason:








1
2
3
4
5
6

-

Received from another health care provider (e.g., physician)
Not eligible / Not indicated
Offered and declined
Not offered
Inability to obtain vaccine due to declared shortage
None of the above

(M1030) Pneumococcal Vaccine: Is the patient's pneumococcal polysaccharide vaccine (PPV) status up to date?

 0 - No (skip pattern removed)
 1 - Yes (skip pattern removed)
 UK - Unknown
(M1031) Pneumococcal Vaccine: Is the patient's pneumococcal polysaccharide vaccine (PPV) status up to date?




0 1 -

No (Complete M1035)
Yes (Skip M1035)

(M1035) If Pneumococcal Vaccine is not up to date, state reason:







(M1040)




1 2 3 -

Not eligible / Not indicated
Offered and declined
Not offered

Guidelines for Physician Notification: Have parameters (limits) related to the patient's health care
problems been established (individually for this patient or using standard guidelines with patient-specific
modifications as needed) for when to contact the physician for vital signs or other clinical findings?
0 1 -

No
Yes

LIVING ARRANGEMENTS
(M0345) Patient Living Situation: Which of the following best describes the patient's residential circumstance and
availability of assistance? (Check one box only).

Living Arrangement
a Patient lives alone

Around
the clock
 01

Availability of Assistance
No assistance
Day only
Night only
available
 02
 03
 04

Unknown
 05

b Patient lives with other person(s)

 06

 07

 08

 09

 10

c Patient lives in congregate situation
(e.g., assisted living)

 11

 12

 13

 14

 15

SENSORY STATUS
(M0390) Vision with corrective lenses if the patient usually wears them:




0 1 -



2 -

(M0405)




Normal vision: sees adequately in most situations; can see medication labels, newsprint.
Partially impaired: cannot see medication labels or newsprint, but can see obstacles in path, and
the surrounding layout; can count fingers at arm's length.
Severely impaired: cannot locate objects without hearing or touching them or patient
nonresponsive.

Ability to hear (with hearing aid or hearing appliance if normally used):
0 1 -

 2  UK -

Adequate: hears normal conversation without difficulty.
Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to
increase volume or speak distinctly.
Severely Impaired: absence of useful hearing.
Unable to assess hearing.

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(M0406)




Understanding of Verbal Content in patient's own language (with hearing aid or device if used):
0 1 -

 2  UK -

Understands: clear comprehension without cues or repetitions.
Usually/Sometimes Understands: Comprehends only basic conversations or simple, direct
phrases or requires cues to understand.
Rarely/Never Understands
Unable to assess understanding.

(M0410) Speech and Oral (Verbal) Expression of Language (in patient's own language):



0 -



1 -



2 -



3 -



4 -



5 -

Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with
no observable impairment.
Minimal difficulty in expressing ideas and needs (may take extra time; makes occasional errors in
word choice, grammar or speech intelligibility; needs minimal prompting or assistance).
Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in
word choice, organization or speech intelligibility). Speaks in phrases or short sentences.
Has severe difficulty expressing basic ideas or needs and requires maximal assistance or
guessing by listener. Speech limited to single words or short phrases.
Unable to express basic needs even with maximal prompting or assistance but is not comatose or
unresponsive (e.g., speech is nonsensical or unintelligible).
Patient nonresponsive or unable to speak.

(M0420) Frequency of Pain interfering with patient's activity or movement:







0
1
2
3
4

-

Patient has no pain (Go to M1070)
Patient has pain that does not interfere with activity or movement
Less often than daily
Daily, but not constantly
All of the time

(M1050) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to
the patient’s ability to verbalize severity of pain)?





0 1 2 -

Yes, and it does not indicate severe or persistent pain
Yes, and it indicates severe or persistent pain
No assessment conducted.

(M1060) Pain Intervention: Is intervention to monitor and mitigate pain severity included in the care plan for this
home health episode of care?




0 1 -

No
Yes

Complete M1065 if M1050 = "1"or if M0420 is greater than "1".
(M1065) Pain Intervention: Have pain management steps been implemented to monitor and mitigate pain severity
during this home health episode of care?




0 - No
1 - Yes

INTEGUMENTARY STATUS
(M1070) Pressure Ulcer Assessment: Was this patient assessed for the Risk of Developing Pressure
Ulcers?





1 2 3 -

No
Yes, using a standardized tool
Yes, using a clinical evaluation

(M0446) Does this patient have a high Risk of Developing Pressure Ulcers?
 0 - No (Skip M1072 at SOC/ROC; Skip M1073 at F/T/D)
 1 - Yes
(M1072) Pressure Ulcer Prevention: Is there a plan for relieving pressure (using a pressure-relieving or
redistributing device such as an enhanced mattress or overlay, or instructing the patient/caregiver in other
methods to reduce pressure)?




0 1 -

No
Yes

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(M1073) Pressure Ulcer Prevention: Was there a plan for relieving pressure (using a pressure-relieving or
redistributing device such as an enhanced mattress or overlay, or instructing the patient/caregiver in other
methods to reduce pressure)?




0 1 -

No
Yes

(M0447) Current Number of Stage I Pressure Ulcers (Intact skin with non-blanchable redness of a localized area
usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to
adjacent tissue.):

 0

 1

 2

 3

 4 or more

(M0448) Does this patient have at least one unhealed (non-epithelialized) Pressure Ulcer at Stage II or higher or
designated as "not stageable"?




0 1 -

No [If No, go to M0465]
Yes

(M0452) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Each Stage: (Circle one response
for each line.)
Stage description – unhealed pressure
ulcers

Number of unhealed pressure
ulcers present

Number with onset during service by
this agency (Omit at SOC/ROC)

a. Stage II: Partial thickness skin loss –
shallow open ulcer with red/pink wound
bed without slough, or blister.
i. Total currently present

0

1

2

3

4 or
more

0

1

2

3

4 or
more

ii. Currently present and known to be
present for at least 30 days

0

1

2

3

4 or
more

0

1

2

3

4 or
more

b. Stage III: Full thickness skin loss--no
exposure of bone, tendon, or muscle

0

1

2

3

4 or
more

UK

0

1

2

3

4 or
more

UK

c. Stage IV: Full thickness tissue loss with
exposed bone, tendon or muscle.
d. Known or likely but not stageable due to
non-removable dressing or cast

0

1

2

3

4 or
more

UK

0

1

2

3

4 or
more

UK

0

1

2

3

4 or
more

UK

0

1

2

3

4 or
more

UK

e. Known but not stageable due to coverage
of wound bed by slough and/or eschar.

0

1

2

3

4 or
more

UK

0

1

2

3

4 or
more

UK

f. Suspected deep tissue injury in evolution.

 0 – No  1 – Yes  UK

 0 – No  1 – Yes  UK

Directions for M0454 and M0456: If the patient has one or more unhealed (non-epithelialized) Stage III or IV
pressure ulcers, identify the pressure ulcer with the longest dimension and record in centimeters:
(M0454) Pressure Ulcer Length: Longest length in any direction | ___ | ___ | . | ___ | (cm)
(M0456) Pressure Ulcer Width: Width of the same pressure ulcer, greatest width measured at right angles to
length | ___ | ___ | . | ___ | (cm)
(M0461) Status of Most Problematic (Observable) Pressure Ulcer:



 0
 1
 2
 3
 NA

-

Re-epithelialized or healed
Fully granulating
Early/partial granulation
Not healing
No observable pressure ulcer

(M0465) [If patient has no pressure ulcers (M0447 = "0" and M0448 = "0", skip to M0469] Stage of Most
Problematic (Observable) Pressure Ulcer:




 1
 2
 3
 4
 NA

-

Stage I
Stage II
Stage III
Stage IV
No observable pressure ulcer

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Complete M1080 if patient has an open Stage II or higher pressure ulcer or a pressure ulcer that is
designated as "not stageable", regardless of whether eschar is present.
(M1080) Pressure Ulcer Intervention: If the patient has an open Stage II or higher pressure ulcer or a pressure
ulcer that is designated as "not stageable", are moisture retentive dressings specified on the plan of care?





0 1 2 -

No
Yes
Moisture retentive dressings not indicated for this patient.

(M1085) Pressure Ulcer Intervention: If the patient had one or more open Stage II or higher pressure ulcers, were
moisture retentive dressings used?





0 1 2 -

No
Yes
Moisture retentive dressings not indicated for this patient

(M0469) Does this patient have a Stasis Ulcer?





0 1 2 -

No [ If No, go to M0483 ]
Yes, patient has one or more (observable) stasis ulcers.
Stasis ulcer known or likely but not observable due to non-removable dressing [ Go to M0483 ]

(M0470) Current Number of (Observable) Stasis Ulcer(s):







0 1 2 3 4 -

Zero
One
Two
Three
Four or more

(M0478) [At follow-up, skip to M0483 if patient has no stasis ulcers] Status of Most Problematic
(Observable) Stasis Ulcer:

 0
 1
 2
 3
 NA



-

Re-epithelialized or healed
Fully granulating
Early/partial granulation
Not healing
No observable stasis ulcer

(M0483) Does this patient have a Surgical Wound?





0 1 2 -

No [ If No, go to M0489 ]
Yes, patient has at least one (observable) surgical wound
Surgical wound known or likely but not observable due to non-removable dressing. [ Go to M0489 ]

(M0487) [At follow-up, skip to M0489 if patient has no surgical wounds] Status of Most Problematic
(Observable) Surgical Wound:

 0
 1
 2
 3
 NA

-

Re-epithelialized or healed
Fully granulating
Early/partial granulation
Not healing
No observable surgical wound

(M0489) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those
described above that is receiving clinical intervention?




0 1 -

No
Yes

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Complete M1090 or M1095 if patient has a diagnosis of diabetes.
(M1090) Foot Care Education: Does the care plan include patient education on both proper foot care and regular
monitoring for the presence of skin lesions on the lower extremities?



 0 - No
 1 - Yes
 NA - Bilateral amputee

(M1095) Foot Care Plan Follow-up: Was the care plan regarding patient education and regular monitoring of foot
care followed?

 0 - No
 1 - Yes
 NA - Bilateral amputee

RESPIRATORY STATUS
(M0490) When is the patient dyspneic or noticeably Short of Breath?





0 1 2 -




3 4 -

Patient is not short of breath
When walking more than 20 feet, climbing stairs
With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less
than 20 feet)
With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation
At rest (during day or night)

(M0500) Respiratory Treatments utilized at home: (Mark all that apply.)






1
2
3
4

-

Oxygen (intermittent or continuous)
Ventilator (continually or at night)
Continuous positive airway pressure
None of the above

CARDIAC STATUS
Complete M1102 (or M1105) & M1110 if patient has a diagnosis of heart failure .
(M1102) Symptoms of Volume Overload: Does the patient exhibit symptoms of volume overload indicated by
clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain)?





0 1 2 -

No (Skip Item M1110)
Yes (Complete Item M1110)
Not assessed. (Skip Item M1110)

(M1105) Symptoms of Volume Overload: Did the patient exhibit symptoms of volume overload indicated by clinical
heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the initial
assessment?





0 1 2 -

No (Skip Item M1110)
Yes (Complete Item M1110)
Not assessed. (Skip Item M1110)

(M1110) Volume Overload Follow-up: What action has been taken to respond to symptoms of volume overload?




0 1 -



2 -

No action taken
Patient’s physician (or other primary care practitioner) contacted the same day, or patient advised
to get emergency treatment (call 911 or go to emergency room)
Other action taken

ELIMINATION STATUS
(M0510) Has this patient been treated for a Urinary Tract Infection in the past 14 days?

 0  1  NA  UK -

No
Yes
Patient on prophylactic treatment
Unknown

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(M0520) Urinary Incontinence or Urinary Catheter Presence:





0 1 2 -

No incontinence or catheter (includes anuria or ostomy for urinary drainage) [ If No, go to M0540 ]
Patient is incontinent
Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to
M0540 ]

(M0530) When does Urinary Incontinence occur?





0 1 2 -

Timed-voiding defers incontinence
During the night only
During the day and night

(M0540) Bowel Incontinence Frequency:

 0  1  2  3  4  5  NA  UK -

Very rarely or never has bowel incontinence
Less than once weekly
One to three times weekly
Four to six times weekly
On a daily basis
More often than once daily
Patient has ostomy for bowel elimination
Unknown

(M0550) 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?




0 1 -



2 -

Patient does not have an ostomy for bowel elimination.
Patient's ostomy was not related to an inpatient stay and did not necessitate change in medical or
treatment regimen.
The ostomy was related to an inpatient stay or did necessitate change in medical or treatment
regimen.

NEURO/EMOTIONAL/BEHAVIORAL STATUS
(M0560) Cognitive Functioning: (Patient's current level of alertness, orientation, comprehension, concentration,
and immediate memory for simple commands.)



0 -




1 2 -



3 -



4 -

Alert/oriented, able to focus and shift attention, comprehends and recalls task directions
independently.
Requires prompting (cuing, repetition, reminders) only under stressful or unfamiliar conditions.
Requires assistance and some direction in specific situations (e.g., on all tasks involving shifting of
attention), or consistently requires low stimulus environment due to distractibility.
Requires considerable assistance in routine situations. Is not alert and oriented or is unable to
shift attention and recall directions more than half the time.
Totally dependent due to disturbances such as constant disorientation, coma, persistent
vegetative state, or delirium.

(M0570) When Confused (Reported or Observed):

 0
 1
 2
 3
 4
 NA

-

Never
In new or complex situations only
On awakening or at night only
During the day and evening, but not constantly
Constantly
Patient nonresponsive

(M0580) When Anxious (Reported or Observed):

 0
 1
 2
 3
 NA

-

None of the time
Less often than daily
Daily, but not constantly
All of the time
Patient nonresponsive

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(M0590) Depressive Symptoms Reported or Observed in Patient: (Mark all that apply.)











1
2
3
4
5
6
7

-

Depressed mood (e.g., feeling sad, tearful)
Sense of failure or self reproach
Hopelessness
Recurrent thoughts of death
Thoughts of suicide
Other signs or symptoms
None of the above feelings observed or reported (Go to M0610)

(M1120) Depression Screening: Has the patient been screened for depression, using a standardized depression
screening tool?





0 1 2 -

No
Yes, and the patient displays no current symptoms of depression. (Go to M0610)
Yes, and the patient displays some symptoms of depression.

(M1130) Depression Intervention/Referral: Is intervention for symptoms of depression or referral for other
treatment or a monitoring plan for current treatment included in the care plan for this home health episode
of care?





0 1 2 -

No
New intervention or referral initiated.
Monitoring plan for patient already on treatment.

(M0610) Behaviors Demonstrated at Least Once a Week (Reported or Observed): (Mark all that apply.)



1 -



2 -




3 4 -





5 6 7 -

Memory deficit: failure to recognize familiar persons/places, inability to recall events of past 24
hours, significant memory loss so that supervision is required
Impaired decision-making: failure to perform usual ADLs or IADLs, inability to appropriately stop
activities, jeopardizes safety through actions
Verbal disruption: yelling, threatening, excessive profanity, sexual references, etc.
Physical aggression: aggressive or combative to self and others (e.g., hits self, throws objects,
punches, dangerous maneuvers with wheelchair or other objects)
Disruptive, infantile, or socially inappropriate behavior (excludes verbal actions)
Delusional, hallucinatory, or paranoid behavior
None of the above behaviors demonstrated

(M0620) Frequency of Behavior Problems (Reported or Observed) (e.g., wandering episodes, self abuse, verbal
disruption, physical aggression, etc.):








0
1
2
3
4
5

-

Never
Less than once a month
Once a month
Several times each month
Several times a week
At least daily

(M0630) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?




0 1 -

No
Yes

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ADL/IADLs
(M0642) Grooming: Current ability to tend to personal hygiene needs (i.e., washing face and hands, hair care,
shaving or make up, teeth or denture care, fingernail care).






0
1
2
3

-

Able to groom self unaided, with or without the use of assistive devices or adapted methods.
Grooming utensils must be placed within reach before able to complete grooming activities.
Someone must assist the patient to groom self.
Patient depends entirely upon someone else for grooming needs.

(M0652) Current Ability to Dress Upper Body (with or without dressing aids) including undergarments, pullovers,
front-opening shirts and blouses, managing zippers, buttons, and snaps:



0 -





1 2 3 -

Able to get clothes out of closets and drawers, put them on and remove them from the upper body
without assistance.
Able to dress upper body without assistance if clothing is laid out or handed to the patient.
Someone must help the patient put on upper body clothing.
Patient depends entirely upon another person to dress the upper body.

(M0662) Current Ability to Dress Lower Body (with or without dressing aids) including undergarments, slacks,
socks or nylons, shoes:




0 1 -




2 3 -

Able to obtain, put on, and remove clothing and shoes without assistance.
Able to dress lower body without assistance if clothing and shoes are laid out or handed to the
patient.
Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.
Patient depends entirely upon another person to dress lower body.

(M0672) Bathing: Current ability to wash entire body SAFELY. Excludes grooming (washing face and hands
only).






0 1 -



2 -



3 -



4 -



5 -



6 -

Able to bathe self in shower or tub independently, including getting in and out of tub/shower.
With the use of devices, is able to bathe self in shower or tub independently, including getting in
and out of the tub/shower.
Able to bathe in shower or tub with the assistance of another person:
(a) for intermittent supervision or encouragement or reminders, OR
(b) to get in and out of the shower or tub, OR
(c) for washing difficult to reach areas.
Able to participate in bathing self in shower or tub, but requires presence of another person
throughout the bath for assistance or supervision.
Able to bath self independently or with the use of devices in chair, or on commode,
but unable to use the shower or tub.
Able to participate in bathing self in bed, bedside chair, or on commode, but requires presence of
another person throughout the bath for assistance or supervision and is unable to use the shower
or tub.
Unable to effectively participate in bathing and is totally bathed by another person.

(M0682) Toilet Transferring: Current ability to get to and from the toilet or bedside commode SAFELY, including
transferring on and off toilet/commode.




0 1 -



2 -



3 -



4 -

Able to get to and from the toilet and transfer independently with or without a device.
When reminded, assisted, or supervised by another person, able to get to and from the toilet and
transfer.
Unable to get to and from the toilet but is able to use a bedside commode (with or without
assistance).
Unable to get to and from the toilet or bedside commode but is able to use a bedpan/urinal
independently.
Is totally dependent in toileting.

(M0684) Toileting Hygiene: Current ability to maintain perineal hygiene, adjust clothes before and after using toilet,
commode, bedpan, urinal. If managing ostomy, include wiping opening but not managing equipment.






0 1 -




2 3 -

Able to manage toileting hygiene without assistance.
Able to manage toileting without assistance if hygiene supplies/implements are laid out for the
patient.
Someone must help the patient to maintain hygiene or adjust clothing.
Patient depends entirely upon another person to maintain toileting hygiene.

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(M0692) Transferring: Current ability to move SAFELY from bed to chair, or ability to turn and position self in bed if
patient is bedfast.








0
1
2
3
4
5

-

Able to independently transfer.
Able to transfer with minimal human assistance or with use of an assistive device.
Unable to transfer self but is able to bear weight and pivot during the transfer process.
Unable to transfer self and is unable to bear weight or pivot when transferred by another person.
Bedfast, unable to transfer but is able to turn and position self in bed.
Bedfast, unable to transfer and is unable to turn and position self.

(M0702) Ambulation/Locomotion: Ability to SAFELY walk, once in a standing position, or use a wheelchair, once
in a seated position, on a variety of surfaces.



0 -



1 -



2 -






3
4
5
6

-

Able to independently walk on even and uneven surfaces and climb stairs with or without railings
(i.e., needs no human assistance or assistive device).
With the use of a cane, able to independently walk on even and uneven surfaces and climb stairs
with or without railings.
Requires use of a walker or crutches to walk alone on a level surface or requires human
supervision or assistance to negotiate stairs or steps or uneven surfaces.
Able to walk only with the supervision or assistance of another person at all times.
Chairfast, unable to ambulate but is able to wheel self independently.
Chairfast, unable to ambulate and is unable to wheel self.
Bedfast, unable to ambulate or be up in a chair.

(M0712) Feeding or Eating: Current ability to feed self meals and snacks. Note: This refers only to the process of
eating, chewing, and swallowing, not preparing the food to be eaten.




0 1 -




2 3 -




4 5 -

Able to independently feed self.
Able to feed self independently but requires:
(a) meal set-up; OR
(b) intermittent assistance or supervision from another person; OR
(c) a liquid, pureed or ground meat diet.
Unable to feed self and must be assisted or supervised throughout the meal/snack.
Able to take in nutrients orally and receives supplemental nutrients through a nasogastric tube or
gastrostomy.
Unable to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.
Unable to take in nutrients orally or by tube feeding.

(M0715) Change in Mobility: Is the patient’s ability to transferring and/or ambulate more impaired better or worse
than it was before the onset of the illness or injury that initiated this episode of care?





0 – Patient at least as able to transfer and ambulate now as s/he was before the onset of the illness or
injury that initiated this episode of care.
1 – Patient is less able to transfer and ambulate now than before the onset of the illness or injury that
initiated this episode of care.
UK – Unknown

(M0717) Change in Self-care Ability: Is the patient's ability to perform self-care activities (grooming, dressing, and
bathing) better or worse than it was before the onset of the illness or injury that initiated this episode of
care?





0 – Patient is at least as able to perform self-care activities now as s/he was before the onset of the
illness or injury that initiated this episode of care.
1 – Patient is less able to perform self-care activities now than before the onset of the illness or injury
that initiated this episode of care.
UK – Unknown

(M0722) Current Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meals:



0 -




1 2 -

(a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR
(b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has
not routinely performed light meal preparation in the past (i.e., prior to this home care
admission).
Unable to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.
Unable to prepare any light meals or reheat any delivered meals.

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(M0742) Laundry: Current ability to do own laundry -- to carry laundry to and from washing machine, to use washer
and dryer, to wash small items by hand.



0 -



1 -



2 -

(a) Able to independently take care of all laundry tasks; OR
(b) Physically, cognitively, and mentally able to do laundry and access facilities, but has not
routinely performed laundry tasks in the past (i.e., prior to this home care admission).
Able to do only light laundry, such as minor hand wash or light washer loads. Due to physical,
cognitive, or mental limitations, needs assistance with heavy laundry such as carrying large loads
of laundry.
Unable to do any laundry due to physical limitation or needs continual supervision and assistance
due to cognitive or mental limitation.

(M0752) Housekeeping: Current ability to safely and effectively perform light housekeeping and heavier cleaning
tasks.



0 -



1 -



2 -



3 -



4 -

(a) Able to independently perform all housekeeping tasks; OR
(b) Physically, cognitively, and mentally able to perform all housekeeping tasks but has not routinely
participated in housekeeping tasks in the past (i.e., prior to this home care admission).
Able to perform only light housekeeping (e.g., dusting, wiping kitchen counters) tasks
independently.
Able to perform housekeeping tasks with intermittent assistance or supervision from another
person.
Unable to consistently perform any housekeeping tasks unless assisted by another person
throughout the process.
Unable to effectively participate in any housekeeping tasks.

(M0762) Shopping: Ability to plan for, select, and purchase items in a store and to carry them home or arrange
delivery.



0 -



1 -



2 -



3 -

(a) Able to plan for shopping needs and independently perform shopping tasks, including carrying
packages; OR
(b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping
in the past (i.e., prior to this home care admission).
Able to go shopping, but needs some assistance:
(a) By self is able to do only light shopping and carry small packages, but needs someone to do
occasional major shopping; OR
(b) Unable to go shopping alone, but can go with someone to assist.
Unable to go shopping, but is able to identify items needed, place orders, and arrange home
delivery.
Needs someone to do all shopping and errands.

(M0772) Ability to Use Telephone: Current ability to answer the phone, dial numbers, and effectively use the
telephone to communicate.




0 1 -



2 -



3 -

 4  5  NA -

Able to dial numbers and answer calls appropriately and as desired.
Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the
deaf) and call essential numbers.
Able to answer the telephone and carry on a normal conversation but has difficulty with placing
calls.
Able to answer the telephone only some of the time or is able to carry on only a limited
conversation.
Unable to answer the telephone at all but can listen if assisted with equipment.
Totally unable to use the telephone.
Patient does not have a telephone.

(M0775) Change in Ability to Perform Routine Household Tasks: Is the patient’s ability to perform routine
household tasks (light housekeeping, light meal preparation, laundry) better or worse now than it was
before the onset of the illness or injury that initiated this episode of care?





0 – Patient is at least as able to perform routine household tasks now as s/he was before the onset of
the illness or injury that initiated this episode of care.
1 – Patient is less able to perform routine household tasks now than before the onset of the illness or
injury that initiated this episode of care.
UK – Unknown

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(M1140) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple
medications, mental impairment, toileting frequency, general mobility/transferring impairment,
environmental hazards)?





0 1 2 -

Yes, and it does not indicate a moderate or high risk for falls. (Skip Item M1150)
Yes, and it indicates a moderate or high risk for falls. (Complete Item M1150)
No multi-factor falls risk assessment conducted. (Skip Item M1150)

(M1150) Falls Risk Intervention: Is intervention to mitigate the risk of falls included in the care plan for this home
health episode of care?




0 1 -

No
Yes

Complete M1155 if previous falls risk assessment indicates the presence or significant risk factors for falls.
(M1155) Falls Risk Intervention: Have fall prevention steps been implemented for this home health episode of
care?




0 1 -

No
Yes

MEDICATIONS
(M1160) Potential Adverse Effects/Reaction: Does a complete drug regimen review indicate potential clinically
significant adverse effects or drug reactions, including ineffective drug therapy, side effects, drug
interactions, duplicate therapy, omissions, dosage errors, or noncompliance?





0 1 2 -

No (Skip Item M1170)
Yes (Complete Item M1170)
Not assessed (Skip Item M1170)

(M1170) Medication Follow-up: Was the patient’s physician (or other primary care practitioner) contacted within
one calendar day to resolve clinically significant medication issues?




0 1 -

No
Yes

(M1180) Patient/Caregiver Drug Education: Has the patient/caregiver been instructed to monitor the effectiveness
of drug therapy and potential adverse effects, and how and when to report problems that may occur?




0 1 -

No
Yes

(M0782) Management of Oral Medications: Patient's current ability to prepare and take all prescribed oral
medications reliably and safely, including administration of the correct dosage at the appropriate
times/intervals. Excludes injectable and IV medications. (NOTE: This refers to ability, not
compliance or willingness.)



0 -



1 -

 2  NA -

Able to independently take the correct oral medication(s) and proper dosage(s) at the correct
times.
Able to take medication(s) at the correct times if:
(a) individual dosages are prepared in advance by another person; OR
(b) given daily reminders; OR
(c) someone develops a drug diary or chart.
Unable to take medication unless administered by someone else.
No oral medications prescribed.

(M0792) Management of Inhalant/Mist Medications: Patient's current ability to prepare and take all prescribed
inhalant/mist medications (nebulizers, metered dose devices, oxygen) reliably and safely, including
administration of the correct dosage at the appropriate times/intervals. Excludes all other forms of
medication (oral tablets, injectable and IV medications).




0 1 -

 2  NA -

Able to independently take the correct medication and proper dosage at the correct times.
Able to take medication at the correct times if:
(a) individual dosages are prepared in advance by another person, OR
(b) given daily reminders.
Unable to take medication unless administered by someone else.
No inhalant/mist medications prescribed.

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(M0802) 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. Excludes IV medications.




0 1 -

 2  NA -

Able to independently take the correct medication and proper dosage at the correct times.
Able to take injectable medication at correct times if:
(a) individual syringes are prepared in advance by another person, OR
(b) given daily reminders.
Unable to take injectable medications unless administered by someone else.
No injectable medications prescribed.

(M0805) Change in Ability to Manage Oral, Inhalant, or Injectable Medications: Is the patient's ability to
prepare and take all prescribed medications (oral and, if applicable, inhalant or injectable medications)
reliably and safely (including administration of the correct dosage at the appropriate times/intervals.) better
or worse than before the onset of the illness or injury that initiated this episode of care?





0 – Patient is at least as able to prepare and take all prescribed medications now than before the
onset of the illness or injury that initiated this episode of care
1 – Patient is less able to prepare and take all prescribed medications now than before the onset of
the illness or injury that initiated this episode of care
UK – Unknown

EQUIPMENT MANAGEMENT
(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral
nutrition equipment or supplies, ventilator therapy equipment or supplies): Patient's ability to set up,
monitor and change equipment reliably and safely, add appropriate fluids or medication,
clean/store/dispose of equipment or supplies using proper technique. (NOTE: This refers to ability, not
compliance or willingness.)




0 1 -



2 -



3 -

 4  NA -

Patient manages all tasks related to equipment completely independently.
If someone else sets up equipment (i.e., fills portable oxygen tank, provides patient with prepared
solutions), patient is able to manage all other aspects of equipment.
Patient requires considerable assistance from another person to manage equipment, but
independently completes portions of the task.
Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else
to manage the equipment.
Patient is completely dependent on someone else to manage all equipment.
No equipment of this type used in care

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(M0822) Type of Assistance needed
Patient needs assistance with
(check all that apply)

a. 

(M0823) Caregiver Assistance
(If patient needs assistance, check one on each row)
Caregiver(s)
will need
Caregiver(s)
Unclear if
No
Caregiver(s)
training and/or
not likely to
Caregiver(s)
Caregiver
provides
other
provide
will provide
available
supportive
services

a. ADL assistance (e.g.,
transfer/ambulation, bathing,
dressing, toileting,
eating/feeding)

a1. 

a2. 

a3. 

a4. 

a5. 

b.



b. IADL assistance (e.g., meals,
housekeeping, laundry,
telephone, shopping, finances)

b1. 

b2. 

b3. 

b4. 

b5. 

c.



c. Medication administration
(e.g., oral, inhaled or
injectable)

c1. 

c2. 

c3. 

c4. 

c5. 

d.



d. Medical procedures/
treatments (e.g., changing
wound dressing)

d1. 

d2. 

d3. 

d4. 

d5. 

e.



e. Management of Equipment
(includes oxygen, IV/infusion
equipment, enteral/parenteral
nutrition, ventilator therapy
equipment or supplies)

e1. 

e2. 

e3. 

e4. 

e5. 

f. Supervision and safety

f1. 

f2. 

f3. 

f4. 

f5. 

g. Advocacy or facilitation of
patient's participation in
appropriate medical care
(includes transportation to or
from appointments)

g1. 

g2. 

g3. 

g4. 

g5. 


g. 
f.

h. 

h. None of the above

(M0824) How Often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home
health agency staff)?



 1
 2
 3
 4
 UK

-

At least daily
Two or more times per week
One to two times per week
Less often than weekly
Unknown*

* at discharge, omit unknown response.

THERAPY NEED
(M0826) Therapy Need: In the home health plan of care for the Medicare payment episode for which this
assessment will define a case mix group, what is the indicated need for therapy visits (total of reasonable
and necessary physical, occupational, and speech-language pathology visits combined)? (Enter zero
[“000”] if no therapy visits indicated.)
(__ __ __) Number of therapy visits indicated (total of physical, occupational and speech-language pathology
combined).
 NA - Not Applicable: No case mix group defined by this assessment.

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Centers for Medicare & Medicaid Services

EMERGENT CARE
(M0831) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hospital
emergency department (includes holding/observation with or without hospital admission)?

 0 - No [ Go to M0855 ]
 1 - Yes
 UK - Unknown [ Go to M0855 ]
(M0845) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or without
hospitalization)? (Mark all that apply.)




























1
2
3
3
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
UK

-

Improper medication administration, medication side effects, toxicity, anaphylaxis
Injury caused by fall or accident at home
Respiratory infection (e.g. pneumonia, bronchitis)
Other respiratory problem
Heart failure (e.g., fluid overload)
Cardiac dysrhythmia (irregular heartbeat)
Myocardial infarction or chest pain
Other heart disease
Stroke (CVA) or TIA
Hypo/Hyperglycemia, diabetes out of control
Upper GI obstruction, constipation, impaction
Dehydration, malnutrition
Urinary tract infection
IV catheter-related infection
Wound infection or deterioration
Uncontrolled pain
Acute mental/behavioral health problem
Deep vein thrombosis, pulmonary embolus
Other than above reasons
Reason unknown

DATA ITEMS COLLECTED AT INPATIENT FACILITY ADMISSION OR AGENCY
DISCHARGE ONLY
(M0855) To which Inpatient Facility has the patient been admitted?

 1
 2
 3
 4
 NA

-

Hospital [ Go to M0896 ]
Rehabilitation facility [ Go to M0903 ]
Nursing home [ Go to M0900 ]
Hospice [ Go to M0903 ]
No inpatient facility admission

(M0870) Discharge Disposition: Where is the patient after discharge from your agency? (Choose only one
answer.)

 1
 2
 3
 UK

- Patient remained in the community (not in hospital, nursing home, or rehab facility)
- Patient transferred to a non-institutional hospice
- Unknown because patient moved to a geographic location not served by this agency
- Other unknown
[ Go to M0903 ]
(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?

 1
 2
 3
 UK

-

Hospitalization for emergent (unscheduled) care
Hospitalization for urgent (scheduled within 24 hours of admission) care
Hospitalization for elective (scheduled more than 24 hours before admission) care
Unknown

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Centers for Medicare & Medicaid Services

(M0896) Reason for Hospitalization: For what reason(s) did the patient require hospitalization?
apply.)



























1
2
3
3
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
UK

-

(Mark all that

Improper medication administration, medication side effects, toxicity, anaphylaxis
Injury caused by fall or accident at home
Respiratory infection (e.g. pneumonia, bronchitis)
Other respiratory problem
Heart failure (e.g., fluid overload)
Cardiac dysrhythmia (irregular heartbeat)
Myocardial infarction or chest pain
Other heart disease
Stroke (CVA) or TIA
Hypo/Hyperglycemia, diabetes out of control
Upper GI obstruction, constipation, impaction
Dehydration, malnutrition
Urinary tract infection
IV catheter-related infection
Wound infection or deterioration
Uncontrolled pain
Acute mental/behavioral health problem
Deep vein thrombosis, pulmonary embolus
Scheduled treatment or procedure
Other than above reasons
Reason unknown

Go to M0903
(M0900) For what Reason(s) was the patient Admitted to a Nursing Home? (Mark all that apply.)

 1
 2
 3
 4
 5
 6
 UK

-

Therapy services
Respite care
Hospice care
Permanent placement
Unsafe for care at home
Other
Unknown

(M0903) Date of Last (Most Recent) Home Visit:
__ __ /__ __ / __ __ __ __
month / day /
year
(M0906) Discharge/Transfer/Death Date: Enter the date of the discharge, transfer, or death (at home) of the
patient.
__ __ /__ __ / __ __ __ __
month / day /
year

CONFIDENTIAL: OASIS-C Changes 2007-10-18
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Centers for Medicare & Medicaid Services