M0010
|
CMS
Certification Number
|
M0010
|
CMS
Certification Number
|
M0014
|
Branch
State
|
M0014
|
Branch
State
|
M0016
|
Branch
ID Number
|
M0016
|
Branch
ID Number
|
M0018
|
National
Provider Identifier (NPI) for
the attending physician who has signed plan of care
|
M0018
|
National
Provider Identifier (NPI) for
the attending physician who has signed plan of care
|
M0020
|
Patient
ID Number
|
M0020
|
Patient
ID Number
|
M0030
|
Start
of Care Date
|
M0030
|
Start
of Care Date
|
M0032
|
Resumption
of Care Date
|
M0032
|
Resumption
of Care Date
|
M0040
|
Patient
Name
|
M0040
|
Patient
Name
|
M0050
|
Patient
State of Residence
|
M0050
|
Patient
State of Residence
|
M0060
|
Patient
Zip Code
|
M0060
|
Patient
Zip Code
|
M0063
|
Medicare
Number
|
M0063
|
Medicare
Number
|
M0064
|
Social
Security Number
|
M0064
|
Social
Security Number
|
M0065
|
Medicaid
Number
|
M0065
|
Medicaid
Number
|
M0066
|
Birth
Date
|
M0066
|
Birth
Date
|
M0069
|
Gender
|
M0069
|
Gender
|
M0080
|
Discipline
of Person Completing Assessment
|
M0080
|
Discipline
of Person Completing Assessment
|
M0090
|
Date
Assessment Completed
|
M0090
|
Date
Assessment Completed
|
M0100
|
This
Assessment is Currently Being Completed for the Following Reason
|
M0100
|
This
Assessment is Currently Being Completed for the Following Reason:
|
M0102
|
Date
of Physician-ordered Start of Care (Resumption of Care):
If the physician indicated a specific start of care (resumption
of care) date when the patient was referred for home health
services, record the date specified.
__
__ /__ __ /____
month/
day / year
(Go
to M0110, if date entered)
⃞ NA
–No specific SOC date ordered by physician
|
M0102
|
Date
of Physician-ordered Start of Care (Resumption of Care): If
the physician indicated a specific start of care (resumption of
care) date when the patient was referred for home health
services, record the date specified.
|
|
/
|
|
|
/
|
|
|
|
|
[Go
to M0110, if date entered
]
|
month
/ day / year
⃞ NA- No
specific SOC date ordered by physician
|
M0104
|
Date
of Referral: Indicate
the date that the written or verbal referral for initiation or
resumption of care was received by the HHA.
__
__ /__ __ /____
month/
day / year
|
M0104
|
Date
of Referral: Indicate
the date that the written or verbal referral for initiation or
resumption of care was received by the HHA.
|
|
/
|
|
|
/
|
|
|
|
|
[Go
to M0110, if date entered
]
|
month/
day / year
|
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?
|
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?
|
M0140
|
Race/Ethnicity
|
M0140
|
Race/Ethnicity
|
M0150
|
Current
Payment Sources for Home Care
|
M0150
|
Current
Payment Sources for Home Care
|
M0903
|
Date
of Last (Most Recent) Home Visit
|
M0903
|
Date
of Last (Most Recent) Home Visit
|
M0906
|
Discharge/Transfer/Death
Date
|
M0906
|
Discharge/Transfer/Death
Date
|
M1000
|
From
which of the following Inpatient
Facilities was
the patient discharged during the past
14
days? (Mark all that apply.)
|
M1000
|
From
which of the following Inpatient
Facilities was
the patient discharged within the past 14 days? (Mark all that
apply.)
|
M1005
|
Inpatient
Discharge Date (most
recent)
|
M1005
|
Inpatient
Discharge Date (most
recent)
|
M1011
|
List
each Inpatient
Diagnosis and
ICD-10-CM code at the level of highest specificity for only those
conditions actively treated during an inpatient stay within the
last 14 days(no V, W, X, Y, or Z codes or surgical codes)
⃞ NA
Not applicable (patient was not discharged from an inpatient
facility) [Omit “NA” option on SOC, ROC]
|
M1011
|
List
each Inpatient
Diagnosis and
ICD-10-CM code at the level of highest specificity for only those
conditions actively treated during an inpatient stay within the
last 14 days (no
V, W, X, Y, or Z codes or surgical codes)
⃞ NA
Not
applicable (patient was not discharged from an inpatient
facility) [Omit “NA” option on SOC, ROC]
|
M1017
|
Diagnoses
Requiring Medical or Treatment Regimen Change Within Past 14
Days: List
the patient's Medical Diagnoses and ICD-10-CM codes at the level
of highest specificity for those conditions requiring changed
medical or treatment regimen within the past 14 days (no V, W, X,
Y, or Z codes or surgical codes)
⃞ NA
Not applicable (no medical or treatment regimen changes within
the past 14 days)
|
M1017
|
Diagnoses
Requiring Medical or Treatment Regimen Change Within Past 14
Days: List
the patient's Medical Diagnoses and ICD-10-CM codes at the level
of highest specificity for those conditions requiring changed
medical or treatment regimen within the past 14 days (no
V, W, X, Y, or Z codes or surgical codes)
⃞ NA
Not applicable (no medical or treatment regimen changes within
the past 14 days)
|
M1018
|
Conditions
Prior to 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 that existed prior
to the inpatient stay or change in medical or treatment regimen
|
M1018
|
Conditions
Prior to 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 that existed prior
to the inpatient stay or change in medical or treatment regimen
|
M1021
|
Primary
Diagnosis &
Degree of Symptom Control
|
M1021
|
Primary
Diagnosis &
Degree of Symptom Control
|
M1023
|
Other
Diagnoses &
Degree of Symptom Control
|
M1023
|
Other
Diagnoses &
Degree of Symptom Control
|
M1025
|
Optional
Diagnoses (OPTIONAL)
(not
used for payment)
|
M1025
|
Optional
Diagnoses (OPTIONAL)
(not
used for payment)
|
|
|
M1028
|
Active
Diagnoses-
Comorbidities and Co-existing Conditions – Check all that
apply. See OASIS Guidance Manual for a complete list of relevant
ICD-10 codes.
|
M1030
|
Therapies
the
patient receives
at home
|
M1030
|
Therapies
the
patient receives
at home
|
M1033
|
Risk
for Hospitalization: Which
of the following signs or symptoms characterize this patient as
at risk for hospitalization? (Mark all that apply.)
|
M1033
|
Risk
for Hospitalization: Which
of the following signs or symptoms characterize this patient as
at risk for hospitalization? (Mark all that apply.)
|
M1034
|
Overall
Status: Which
description best fits the patient’s overall status?
|
M1034
|
Overall
Status: Which
description best fits the patient’s overall status?
|
M1036
|
Risk
Factors
|
M1036
|
Risk
Factors
|
M1041
|
Influenza
Vaccine Data Collection Period: Does
this episode of care (SOC/ROC to Transfer/Discharge) include any
dates on or between October 1 and March 31?
|
M1041
|
Influenza
Vaccine Data Collection Period: Does
this episode of care (SOC/ROC to Transfer/Discharge) include any
dates on or between October 1 and March 31?
|
M1046
|
Influenza
Vaccine Received: did
the patient receive the influenza vaccine for this year’s
flu season?
|
M1046
|
Influenza
Vaccine Received: did
the patient receive the influenza vaccine for this year’s
flu season?
|
M1051
|
Pneumococcal
Vaccine:
Has the patient ever received the pneumococcal vaccination (for
example, pneumovax)?
|
M1051
|
Pneumococcal
Vaccine:
Has the patient ever received the pneumococcal vaccination (for
example, pneumovax)?
|
M1056
|
Reason
PPV not received:
If patient has never received the pneumococcal vaccination (for
example, pneumovax), state reason:
|
M1056
|
Reason
PPV not received:
If patient has never received the pneumococcal vaccination (for
example, pneumovax), state reason:
|
|
|
M1060
|
Height
and Weight – While
measuring, if the number is X.1 – X.4 round down; X.5 or
greater round up a.
Height (in inches). Record most recent height measure since the
most recent SOC/ROC b. Weight (in pounds). Base weight on most
recent measure in last 30 days; measure weight consistently,
according to standard agency practice (for example, in a.m. after
voiding, before meal, with shoes off, etc.).
b.
Weight (in pounds). Base weight on most recent measure in last 30
days; measure weight consistently, according to standard agency
practice (for example, in a.m. after voiding, before meal, with
shoes off, etc.)
a.
Height (in inches). Record most recent height measure since the
most recent SOC/ROC
b.
Weight (in pounds). Base weight on most recent measure in last 30
days; measure weight consistently, according to standard agency
practice (for example, in a.m. after voiding, before meal, with
shoes off, etc.)
|
M1100
|
Patient
Living Situation Which
of the following best describes the patient's residential
circumstance and availability of assistance? (Check one box
only.)
|
M1100
|
Patient
Living Situation Which
of the following best describes the patient's residential
circumstance and availability of assistance? (Check one box
only.)
|
M1200
|
Vision
(with
corrective lenses if the patient usually wears them):
|
M1200
|
Vision
(with
corrective lenses if the patient usually wears them):
|
M1210
|
Ability
to hear (with
hearing aid or hearing appliance if normally used):
|
M1210
|
Ability
to Hear (with
hearing aid or hearing appliance if normally used):
|
M1220
|
Understanding
of Verbal Content in
patient's own language (with hearing aid or device if used):
|
M1220
|
Understanding
of Verbal
Content
in
patient's own language (with hearing aid or device if used):
|
M1230
|
Speech
and Oral (Verbal) Expression of Language (in
patient's own language):
|
M1230
|
Speech
and Oral (Verbal) Expression of Language (in
patient's own language):
|
M1240
|
Has
this patient had a formal Pain
Assessment using
a standardized, validated pain assessment tool (appropriate to
the patient’s ability to communicate the severity of pain)?
|
M1240
|
Has
this patient had a formal Pain
Assessment using
a standardized, validated pain assessment tool (appropriate to
the patient’s ability to communicate the severity of pain)?
|
M1242
|
Frequency
of Pain Interfering with
patient's activity or movement
|
M1242
|
Frequency
of Pain Interfering with
patient's activity or movement:
|
M1300
|
Pressure
Ulcer Assessment:
Was this patient assessed for Risk of Developing Pressure Ulcers?
|
M1300
|
Pressure
Ulcer Assessment:
Was this patient assessed for Risk of Developing Pressure Ulcers?
|
M1302
|
Does
this patient have a Risk
of Developing Pressure Ulcers
|
M1302
|
Does
this patient have a Risk
of Developing Pressure Ulcers
|
M1306
|
Does
this patient have at least one Unhealed
Pressure Ulcer at Stage II or Higher or
designated as "unstageable"? (Excludes
Stage I pressure ulcers and healed Stage II pressure ulcers)
|
M1306
|
Does
this patient have at least one Unhealed
Pressure Ulcer at Stage 2 or Higher or
designated as "unstageable"? (Excludes Stage 1 pressure
ulcers and healed Stage 2 pressure ulcers)
|
M1307
|
The
Oldest
Stage II Pressure Ulcer that
is present at discharge (Excludes healed stage II pressure
ulcers)
|
M1307
|
The
Oldest
Stage 2 Pressure Ulcer that
is present at discharge (Excludes healed Stage 2 pressure ulcers)
|
M1308
|
Current
Number of Unhealed Pressure Ulcers at Each Stage or Unstageable:
(Enter
“0” if none; EXCLUDES Stage I pressure ulcers and
healed Stage II ulcers)
|
M1311
|
Current
Number of Unhealed Pressure Ulcers at Each Stage
|
M1309
|
Worsening
in Pressure Ulcer Status since SOC/ROC
Instructions
a-c: For Stage II, III, IV pressure ulcers, report the number
that are new or have increased in numerical stage since the most
recent SOC/ROC
Instructions
for d: For pressure ulcers that are Unstageable due to
slough/eschar, report the number that are new or were a Stage I
or II at the most SOC/ROC
|
M1313
|
Worsening
in Pressure Ulcer Status since SOC/ROC: Indicate the number of
current pressure ulcers that were not present or were at a lesser
stage at the most recent
SOC/ROC. If no current pressure ulcer at a given stage, enter 0.
A1.
Stage 2: Partial
thickness loss of dermis presenting as a shallow open ulcer with
red pink wound bed, without slough. May also present as an
intact or open/ruptured blister.
Number
of Stage 2 pressure ulcers
A2.
Number of these
Stage 2 pressure ulcers that were present at most recent SOC/ROC
B1.
Stage 3:
Full thickness tissue loss. Subcutaneous fat may be visible but
bone, tendon, or muscle is not exposed. Slough may be present but
does not obscure the depth of tissue loss. May include
undermining and tunneling. Number of Stage 3 pressure ulcers
B2.
Number of these
Stage 3 pressure ulcers that were present at most recent SOC/ROC
C1.
Stage 4:
Full thickness tissue loss with exposed bone, tendon, or muscle.
Slough or eschar may be present on some parts of the wound bed.
Often includes undermining and tunneling. Number of Stage 4
pressure ulcers.
C2.
Number of these
Stage 4 pressure ulcers that were present at most recent SOC/ROC.
D1.
Unstageable: Non-removable dressing: Known but not stageable due
to non-removable dressing/device. Number of unstageable pressure
ulcers due to non-removable dressing/device
D2.
Number of these unstageable pressure ulcers that were present at
most recent SOC/ROC
E1.
Unstageable: Slough and/or eschar: Known but not stageable due to
coverage of wound bed by slough and/or eschar
E2.
Number of these unstageable pressure ulcers that were present at
most recent SOC/ROC
F1.
Unstageable: Deep tissue injury: Suspected deep tissue injury in
evolution Number of unstageable pressure ulcers with
suspected deep tissue injury in evolution
F2.
Number of these unstageable pressure ulcers that were present at
most recent SOC/ROC
[Omit
“A2, B2, C2, D2, E2 and F2” on SOC/ROC ]
|
|
|
M1313
|
Worsening
in Pressure Ulcer Status since SOC/ROC:
Instructions
for a-c: Indicate the number of current pressure ulcers that were
not present or were at a lesser stage at the most recent SOC/ROC.
If no current pressure ulcer at a given stage, enter 0.
Stage
2
Stage
3
Stage
4
|
|
|
M1313
|
Instructions
for e: For pressure ulcers that are Unstageable due to
slough/eschar, report the number that are new or were at a Stage
1 or 2 at the most recent SOC/ROC.
a.
Unstageable – Known or likely but Unstageable due to
non-removable dressing.
b.
Unstageable – Known or likely but Unstageable due to
coverage of wound bed by slough and/or eschar.
c.
Unstageable – Suspected deep tissue injury in evolution.
|
M1320
|
Status
of Most Problematic Pressure Ulcer that is Observable
|
M1320
|
Status
of Most Problematic Pressure Ulcer that is Observable
|
M1322
|
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.
|
M1322
|
Current
Number of Stage 1 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. Darkly pigmented skin may
not have a visible blanching; in dark skin tones only it may
appear with persistent blue or purple hues.
|
M1324
|
Stage
of Most Problematic Unhealed Pressure
Ulcer that is Stageable
1 Stage
I
2 Stage
II
3 Stage
III
4 Stage
IV
NA Patient
has no pressure ulcers or no stageable pressure ulcers
|
|
Stage
of Most Problematic Unhealed Pressure Ulcer that is Stageable
1 Stage
1
2 Stage
2
3 Stage
3
4 Stage
4
NA Patient
has no pressure ulcers or no stageable pressure ulcers
|
M1330
|
Does
this patient have a Stasis
Ulcer?
|
M1330
|
Does
this patient have a Stasis
Ulcer?
|
M1332
|
Current
Number of
Stasis
Ulcer(s) that are Observable
|
M1332
|
Current
Number of (Observable) Stasis Ulcer(s)
|
M1334
|
Status
of Most Problematic Stasis Ulcer that is Observable
|
M1334
|
Status
of Most Problematic Stasis Ulcer that is Observable
|
M1340
|
Does
this patient have a Surgical
Wound?
|
M1340
|
Does
this patient have a Surgical
Wound?
|
M1342
|
Status
of Most Problematic Surgical Wound that is Observable
|
M1342
|
Status
of Most Problematic Surgical Wound that is Observable
|
M1350
|
Does
this patient have a Skin
Lesion or Open Wound (excluding
bowel ostomy), other than those described above, that
is receiving
intervention
by the home health agency?
|
M1350
|
Does
this patient have a Skin
Lesion or Open Wound (excluding
bowel ostomy), other than those described above, that
is receiving
intervention
by the home health agency?
|
M1400
|
When
is the patient dyspneic or noticeably Short
of Breath?
|
M1400
|
When
is the patient dyspneic or noticeably Short
of Breath?
|
M1410
|
Respiratory
Treatments utilized
at home: (Mark
all that apply.)
|
M1410
|
Respiratory
Treatments utilized
at home: (Mark
all that apply.)
|
M1500
|
Symptoms
in Heart Failure Patients:
If
patient has been diagnosed with heart failure, did the patient
exhibit symptoms indicated by clinical heart failure guidelines
(including dyspnea, orthopnea, edema, or weight gain) at the time
of or at any time since the previous OASIS
assessment?
|
M1501
|
Symptoms
in Heart Failure Patients: If
patient has been diagnosed with heart failure, did the patient
exhibit symptoms indicated by clinical heart failure guidelines
(including dyspnea, orthopnea, edema, or weight gain) at the time
of or at any time since the most recent SOC/ROC assessment?
|
M1510
|
Heart
Failure Follow-up:
If patient has been diagnosed with heart failure and has
exhibited symptoms indicative of heart failure at the time of or
at any time since the previous OASIS assessment, what action(s)
has (have) been taken to respond? (Mark all that apply.)
|
M1511
|
Heart
Failure Follow-up: If
patient has been diagnosed with heart failure and has exhibited
symptoms indicative of heart failure at the time of or at any
time since the most recent SOC/ROC assessment, what action(s) has
(have) been taken to respond? (Mark all that apply.)
|
M1600
|
Has
this patient been treated for a Urinary
Tract Infection in
the past 14 days?
|
M1600
|
Has
this patient been treated for a Urinary
Tract Infection in
the past 14 days?
|
M1610
|
Urinary
Incontinence or Urinary Catheter Presence
|
M1610
|
Urinary
Incontinence or Urinary Catheter Presence
|
M1615
|
When
does
Urinary
Incontinence
occur?
|
M1615
|
When
does
Urinary
Incontinence
occur?
|
M1620
|
Bowel
Incontinence Frequency
|
M1620
|
Bowel
Incontinence Frequency
|
M1630
|
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?
|
M1630
|
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?
|
M1700
|
Cognitive
Functioning: Patient's
current (day of assessment) level of alertness, orientation,
comprehension, concentration, and immediate memory for simple
commands.
|
M1700
|
Cognitive
Functioning: Patient's
current (day of assessment) level of alertness, orientation,
comprehension, concentration, and immediate memory for simple
commands.
|
M1710
|
When
Confused (Reported or Observed Within the Last 14 Days)
|
M1710
|
When
Confused (Reported or Observed Within the Last 14 Days)
|
M1720
|
When
Anxious (Reported or Observed Within the Last 14 Days)
|
M1720
|
When
Anxious (Reported or Observed Within the Last 14 Days)
|
M1730
|
Depression
Screening: Has
the patient been screened for depression, using a standardized,
validated depression screening tool?
|
M1730
|
Depression
Screening: Has
the patient been screened for depression, using a standardized,
validated depression screening tool?
|
M1740
|
Cognitive,
behavioral, and psychiatric symptoms that
are demonstrated at least once a week (Reported or Observed):
(Mark
all that apply.)
|
M1740
|
Cognitive,
behavioral, and psychiatric symptoms that
are demonstrated at least once a week (Reported or Observed):
(Mark
all that apply.)
|
M1745
|
Frequency
of Disruptive Behavior Symptoms (Reported or Observed) Any
physical, verbal, or other disruptive/dangerous symptoms that are
injurious to self or others or jeopardize personal safety.
|
M1745
|
Frequency
of Disruptive Behavior Symptoms (Reported or Observed) Any
physical, verbal, or other disruptive/dangerous symptoms that are
injurious to self or others or jeopardize personal safety.
|
M1750
|
Is
this patient receiving
Psychiatric
Nursing Services at
home provided by a qualified psychiatric nurse?
|
M1750
|
Is
this patient receiving
Psychiatric
Nursing Services at
home provided by a qualified psychiatric nurse?
|
M1800
|
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).
|
M1800
|
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).
|
M1810
|
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:
|
M1810
|
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:
|
M1820
|
Current
Ability
to Dress Lower Body safely
(with or without dressing aids) including undergarments, slacks,
socks or nylons, shoes:
|
M1820
|
Current
Ability
to Dress Lower Body safely
(with or without dressing aids) including undergarments, slacks,
socks or nylons, shoes:
|
M1830
|
Bathing:
Current
ability to wash entire body safely. Excludes
grooming (washing face, washing hands, and shampooing hair).
|
M1830
|
Bathing:
Current
ability to wash entire body safely. Excludes
grooming (washing face, washing hands, and shampooing hair).
|
M1840
|
Toilet
Transferring: Current
ability to get to and from the toilet or bedside commode safely
and transfer on and off toilet/commode.
|
M1840
|
Toilet
Transferring: Current
ability to get to and from the toilet or bedside commode safely
and transfer on and off toilet/commode.
|
M1845
|
Toileting
Hygiene: Current
ability to maintain perineal hygiene safely, adjust clothes
and/or incontinence pads before and after using toilet, commode,
bedpan, urinal. If managing ostomy, includes cleaning area around
stoma, but not managing equipment.
|
M1845
|
Toileting
Hygiene: Current
ability to maintain perineal hygiene safely, adjust clothes
and/or incontinence pads before and after using toilet, commode,
bedpan, urinal. If managing ostomy, includes cleaning area around
stoma, but not managing equipment.
|
M1850
|
Transferring:
Current
ability to move safely from bed to chair, or ability to turn and
position self in bed if patient is bedfast.
|
M1850
|
Transferring:
Current
ability to move safely from bed to chair, or ability to turn and
position self in bed if patient is bedfast.
|
|
|
GG0170C
(Sect. GG)
|
Code
the patient’s usual performance at the SOC/ROC using the
6-point scale. If activity was not attempted at SOC/ROC, code
the reason. Code the patient’s discharge goal using the
6-point scale. Do not use codes 07, 09, or 88 to code discharge
goal.
Lying to Sitting on Side of Bed: The ability to safely move from
lying on the back to sitting on the side of the bed with feet
flat on the floor, and with no
back
support.
|
M1860
|
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.
|
M1860
|
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.
|
M1870
|
Feeding
or Eating: Current
ability to feed self-meals and snacks safely. Note: This refers
only to the process of eating,
chewing,
and swallowing, not
preparing
the food to be eaten.
|
M1870
|
Feeding
or Eating: Current
ability to feed self-meals and snacks safely. Note: This refers
only to the process of eating,
chewing,
and swallowing, not
preparing
the food to be eaten.
|
M1880
|
Current
Ability
to Plan and Prepare Light Meals (for
example, cereal, sandwich) or reheat delivered meals safely:
|
M1880
|
Current
Ability
to Plan and Prepare Light Meals
(for example, cereal, sandwich) or reheat delivered meals safely:
|
M1890
|
Ability
to Use Telephone:
Current ability to answer the phone safely, including dialing
numbers, and effectively using the telephone
to communicate.
|
M1890
|
Ability
to Use Telephone:
Current ability to answer the phone safely, including dialing
numbers, and effectively using the
telephone
to communicate.
|
M1900
|
Prior
Functioning ADL/IADL: Indicate
the patient’s usual ability with everyday activities prior
to this current illness, exacerbation, or injury. Check only one
box in each
row.
Household
tasks (specifically: light meal preparation, laundry, shopping,
and phone use )
Transfer
Ambulation
Self-Care
(specifically: grooming, dressing, bathing, and toileting
hygiene)
|
M1900
|
Prior
Functioning ADL/IADL: Indicate
the patient’s usual ability with everyday activities prior
to this current illness, exacerbation, or injury.
Household
tasks (specifically: light meal preparation, laundry, shopping,
and phone use )
Transfer
Ambulation
Self-Care
(specifically: grooming, dressing, bathing, and toileting
hygiene)
|
M1910
|
Has
this patient had a multi-factor Falls
Risk Assessment using
a standardized, validated assessment tool?
|
M1910
|
Has
this patient had a multi-factor Falls
Risk Assessment using
a standardized, validated assessment tool?
|
M2000
|
Drug
Regimen Review: Does
a complete drug regimen review indicate potential clinically
significant medication issues (for example, adverse drug
reactions, ineffective drug therapy, significant side effects,
drug interactions, duplicate therapy, omissions, dosage errors,
or noncompliance [non-adherence])?
|
M2001
|
Drug
Regimen Review: Did
a complete drug regimen review identify potential clinically
significant medication issues?
|
M2002
|
Medication
Follow-up: Was
a physician or the physician-designee contacted within one
calendar day to resolve clinically significant medication issues,
including reconciliation?
|
M2003
|
Medication
Follow-up: Did
the agency contact a physician (or physician-designee) by
midnight of the next calendar day and complete
prescribed/recommended actions in response to the
identified
potential clinically significant medication issues?
|
M2004
|
Medication
Intervention: If
there were any clinically significant medication issues at the
time of, or at any time since the previous OASIS assessment, was
a physician or the physician- designee contacted within one
calendar day to resolve any identified clinically significant
medication issues, including reconciliation?
|
M2005
|
Medication
Intervention: Did
the agency contact and complete physician (or physician-designee)
prescribed/recommended actions by midnight of the next calendar
day each time potential clinically significant medication issues
were identified since the SOC/ROC?
|
M2010
|
Patient/Caregiver
High Risk Drug Education: Has
the patient/caregiver received instruction on special precautions
for all high-risk medications (such as hypoglycemics,
anticoagulants, etc.) and how and when to report problems that
may occur?
|
M2010
|
Patient/Caregiver
High Risk Drug Education: Has
the patient/caregiver received instruction on special precautions
for all high-risk medications (such as hypoglycemics,
anticoagulants, etc.) and how and when to report problems that
may occur?
|
M2015
|
Patient/Caregiver
Drug Education Intervention:
At the time of, or at any time since the previous OASIS
assessment, was the patient/caregiver instructed by agency staff
or other health care provider to monitor the effectiveness of
drug therapy, adverse drug reactions, and significant side
effects, and how and when to report problems that may occur?
|
M2016
|
Patient/Caregiver
Drug Education Intervention: At
the time of, or at any time since the most recent SOC/ROC
assessment, was the patient/caregiver instructed by agency staff
or other health care provider to monitor the effectiveness of
drug therapy, adverse drug reactions, and significant side
effects, and how and when to report
problems
that may occur?
|
M2020
|
Management
of Oral Medications: Patient's
current
ability
to prepare and take all 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.)
|
M2020
|
Management
of Oral Medications: Patient's
current
ability
to prepare and take all 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.)
|
M2030
|
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.
|
M2030
|
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.
|
M2040
|
Prior
Medication Management: Indicate
the patient’s usual ability with managing oral and
injectable medications prior to his/her most recent illness,
exacerbation or injury. Check only one box in each row.
Injectable
medications
Oral
medications
|
M2040
|
Prior
Medication Management: Indicate
the patient’s usual ability with managing oral and
injectable medications prior to his/her most recent illness,
exacerbation or injury. Check only one box in each row.
Injectable
medications
Oral
medications
|
M2102
|
Types
and Sources of
Assistance:
Determine
the ability and willingness of non-agency caregivers (such as
family members, friends, or privately paid caregivers) to provide
assistance for the following activities, if assistance is needed.
Excludes
all care by your agency staff. (Check only one box in
each row.)
ADL
assistance
IADL
assistance
Medication
administration
Medical
procedures/ treatments
Management
of Equipment
Supervision
and safety
Advocacy
or facilitation
|
M2102
|
Types
and Sources of
Assistance:
Determine
the ability and willingness of non-agency caregivers (such as
family members, friends, or privately paid caregivers) to provide
assistance for the following activities, if assistance is needed.
Excludes
all care by your agency staff.
ADL
assistance
IADL
assistance
Medication
administration
Medical
procedures/ treatments
Management
of Equipment
Supervision
and safety
Advocacy
or facilitation
|
M2110
|
How
Often does
the patient receive ADL
or IADL assistance from
any caregiver(s) (other than home health agency staff)?
|
M2110
|
How
Often does
the patient receive ADL
or IADL assistance from
any caregiver(s) (other than home health agency staff)?
|
M2200
|
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.)
|
M2200
|
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.)
|
M2250
|
Plan
of Care Synopsis: (Check
only one box in each row.) Does the physician-ordered plan of
care include the following:
|
M2250
|
Plan
of Care Synopsis: (Check
only one box in each row.) Does the physician-ordered plan of
care include the following:
|
M2300
|
Emergent
Care: At
the time of or at any time since the previous OASIS assessment
has the patient utilized a hospital emergency department
(includes holding/observation status)?
|
M2301
|
Emergent
Care: At
the time of or at any time since the most recent SOC/ROC
assessment has the patient utilized a hospital emergency
department (includes holding/observation status)?
|
M2310
|
Reason
for Emergent Care:
For what reason(s) did the patient seek and/or receive emergent
care (with or without hospitalization)?
|
M2310
|
Reason
for Emergent Care:
For what reason(s) did the patient seek and/or receive emergent
care (with or without hospitalization)?
|
M2400
|
Intervention
Synopsis -
(Check only one box in each row.) At the time of or at any time
since the previous OASIS assessment, were the following
interventions BOTH included in the physician-ordered plan of care
AND implemented?
|
M2401
|
Intervention
Synopsis: (Check
only one box in each row.) At the time of or at any time since
the most recent SOC/ROC assessment, were the following
interventions BOTH included in the physician-ordered plan of care
AND implemented?
|
M2410
|
To
which Inpatient
Facility has
the patient been admitted?
|
M2410
|
To
which Inpatient
Facility has
the patient been admitted?
|
M2420
|
Discharge
Disposition: Where
is the patient after discharge from your agency? (Choose
only one answer.)
|
M2420
|
Discharge
Disposition: Where
is the patient after discharge from your agency? (Choose
only one answer.)
|
M2430
|
Reason
for Hospitalization:
For what reason(s) did the patient require hospitalization? (Mark
all that apply.)
|
M2430
|
Reason
for Hospitalization:
For what reason(s) did the patient require hospitalization? (Mark
all that apply.)
|
M0903
|
Date
of Last (Most Recent) Home Visit:
|
M0903
|
Date
of Last (Most Recent) Home Visit:
|
M0906
|
Discharge/Transfer/Death
Date: Enter the date of the discharge, transfer, or death (at
home) of the patient.
|
M0906
|
Discharge/Transfer/Death
Date: Enter the date of the discharge, transfer, or death (at
home) of the patient.
|