CMS-10238 - OASIS Instrument (Revised)

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:

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

(M0069) Gender:
1 2 -

Male
Female

(M0072) Primary Referring Physician ID:
UK – Unknown or Not Available

__ __ __ __ __ __ __ __ __ __
(M0140) Race/Ethnicity: (Mark all that apply.)
1
2
3
4
5
6

-

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

CONFIDENTIAL: OASIS Changes 2007-10-18
DO NOT DISSEMINATE

1

Centers for Medicare & Medicaid Services