Form CMS-10545 OASIS-D Item Set

Outcome and Assessment Information Set (OASIS-D) (CMS-10545)

Attachment-B-OASIS-D1_All Items

Medicare and Medicaid OASIS Collection Requirements (Data Collection)

OMB: 0938-1279

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1279 can be found here:

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OMB #0938-1279 Expiration date XX/XX/XXXX

Home Health Patient Tracking Sheet
(M0010) CMS Certification Number:
(M0014) Branch State:
(M0016) Branch ID Number:
(M0018) National Provider Identifier (NPI) for the attending physician who has signed the plan of care:
⃞ UK – Unknown or Not Available

(M0020) Patient ID Number:
(M0030) Start of Care Date:

/
month

/
day

(M0032) Resumption of Care Date:

year
/

month

day

year

(M0040) Patient Name:
(First)

(M I)

(Last)

⃞ NA – Not Applicable

(Suffix)

(M0050) Patient State of Residence:
─

(M0060) Patient ZIP Code:
(M0063) Medicare Number:
(including suffix)
(M0064) Social Security Number:

/
month

/
day

⃞ UK – Unknown or Not Available
⃞ NA – No Medicaid

(M0065) Medicaid Number:
(M0066) Birth Date:

⃞ NA – No Medicare

year

PRA Disclosure Statement
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 number for this information collection is
0938-1279. The expiration date is XX/XX/XXXX. The time required to complete this information collection is estimated
to be 53.1 minutes (0.3 minutes per data element), including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. This estimate does not
include time for training. 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, Mail Stop
C4-26-05, Baltimore, Maryland 21244-1850.
*****CMS Disclaimer*****Please do not send applications, claims, payments, medical records or any documents
containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not
pertaining to the information collection burden approved under the associated OMB control number listed on this form
will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your
documents, please contact Joan Proctor National Coordinator, Home Health Quality Reporting Program Centers for
Medicare & Medicaid.
OASIS-D1 – All Item Set
Effective XX/XX/XXXX
Centers for Medicare & Medicaid Services

Page 1 of 31

(M0069) Gender
Enter Code

1
2

Male
Female

(M0140) Race/Ethnicity: (Mark all that apply.)

⃞

1 -

American Indian or Alaska Native

⃞

2 -

Asian

⃞

3 -

Black or African-American

⃞

4 -

Hispanic or Latino

⃞

5 -

Native Hawaiian or Pacific Islander

⃞

6 -

White

(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 (for example, Title III, V, or XX)

⃞

7 -

Other government (for example, TriCare, VA)

⃞

8 -

Private insurance

⃞

9 -

Private HMO/managed care

⃞ 10 - Self-pay
⃞ 11 - Other (specify)
⃞ UK - Unknown

OASIS-D1 – All Item Set
Effective XX/XX/XXXX
Centers for Medicare & Medicaid Services

Page 2 of 31

Outcome and Assessment Information Set
Items to be Used at Specific Time Points
Time Point

Items Used

Start of Care --------------------------------------------------------

M0010-M0030, M0040-M0150, M1000-M1033,
M1060-M1306, M1311-M2003, M2010, M2020M2200, GG0100-GG0170

Start of care – further visits planned
Resumption of Care --------------------------------------------Resumption of care (after inpatient stay)
Follow-Up ----------------------------------------------------------Recertification (follow-up) assessment
Other follow-up assessment
Transfer to an Inpatient Facility -----------------------------Transferred to an inpatient facility – patient not
discharged from an agency
Transferred to an inpatient facility – patient
discharged from agency

M0032, M0080-M0110, M1000-M1033, M1060M1306, M1311-M2003, M2010, M2020-M2200,
GG0100-GG0170
M0080-M0100, M0110, M1021- M1023, M1030M1033, M1200-M1306, M1311-M1400, M1610M1630, M1800-M1840, M1850-M1860, M2030,
M2200, GG0130-GG0170
M0080-M0100, M1041-M1056, M2005, M2016,
M2301-M2410, M0906, J1800-J1900

Discharge from Agency – Not to an Inpatient Facility
Death at home -------------------------------------------------

M0080-M0100, M2005, M0906, J1800-J1900

Discharge from agency --------------------------------------

M0080-M0100, M1041-M1056, M1242-M1311,
M1324-M1330, M1334-M1600, M1620, M1700M1720, M1740-M1870, M2005, M2016-M2020,
M2102, M2301-M2420, M0906, GG0130-J1900

CLINICAL RECORD ITEMS
(M0080)

Discipline of Person Completing Assessment

Enter Code

1
2
3
4

RN
PT
SLP/ST
OT

(M0090) Date Assessment Completed:

/
month

/
day

year

(M0100)

This Assessment is Currently Being Completed for the Following Reason:

Enter Code

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 M1041]
7
Transferred to an inpatient facility – patient discharged from agency [Go to M1041]
Discharge from Agency – Not to an Inpatient Facility
8
Death at home [Go to M2005]
9
Discharge from agency [Go to M1041]

OASIS-D1 – All Item Set
Effective XX/XX/XXXX
Centers for Medicare & Medicaid Services

Page 3 of 31

CLINICAL RECORD ITEMS, continued
(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

[Go to M0110, if date entered ]

/
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

(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?

Enter Code

1
2
UK
NA

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

PATIENT HISTORY AND DIAGNOSES
(M1000) From which of the following Inpatient Facilities was the patient discharged within the past 14 days? (Mark
all that apply.)

⃞

1 -

Long-term nursing facility (NF)

⃞

2 -

Skilled nursing facility (SNF/TCU)

⃞

3 -

Short-stay acute hospital (IPPS)

⃞

4 -

Long-term care hospital (LTCH)

⃞

5 -

Inpatient rehabilitation hospital or unit (IRF)

⃞

6 -

Psychiatric hospital or unit

⃞

7 -

Other (specify)

⃞ NA - Patient was not discharged from an inpatient facility [Go to M1021]
(M1005) Inpatient Discharge Date (most recent):

/
month

/
day

year

⃞ UK - Unknown

OASIS-D1 – All Item Set
Effective XX/XX/XXXX
Centers for Medicare & Medicaid Services

Page 4 of 31

PATIENT HISTORY AND DIAGNOSES, continued
(M1021/1023) Diagnoses and Symptom Control: List each diagnosis for which the patient is receiving home care in
Column 1, and enter its ICD-10-CM code at the level of highest specificity in Column 2 (diagnosis codes only – no
surgical or procedure codes allowed). Diagnoses are listed in the order that best reflects the seriousness of each
condition and supports the disciplines and services provided. Rate the degree of symptom control for each condition
in Column 2. ICD-10-CM sequencing requirements must be followed if multiple coding is indicated for any diagnoses.
Code each row according to the following directions for each column:
Column 1:

Enter the description of the diagnosis. Sequencing of diagnoses should reflect the seriousness of each
condition and support the disciplines and services provided.

Column 2:

Enter the ICD-10-CM code for the condition described in Column 1 – no surgical or procedure codes
allowed. Codes must be entered at the level of highest specificity and ICD-10-CM coding rules and
sequencing requirements must be followed. Note that external cause codes (ICD-10-CM codes
beginning with V, W, X, or Y) may not be reported in M1021 (Primary Diagnosis) but may be reported in
M1023 (Secondary Diagnoses). Also note that when a Z-code is reported in Column 2, the code for the
underlying condition can often be entered in Column 2, as long as it is an active on-going condition
impacting home health care.
Rate the degree of symptom control for the condition listed in Column 1. Do not assign a symptom
control rating if the diagnosis code is a V, W, X, Y or Z-code. Choose one value that represents the
degree of symptom control appropriate for each diagnosis 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
Note that the rating for symptom control in Column 2 should not be used to determine the sequencing of
the diagnoses listed in Column 1. These are separate items and sequencing may not coincide.

(Form on next page)

OASIS-D1 – All Item Set
Effective XX/XX/XXXX
Centers for Medicare & Medicaid Services

Page 5 of 31

(M1021) Primary Diagnosis & (M1023) Other Diagnoses
Column 1

Column 2

Diagnoses (Sequencing of diagnoses should reflect the
seriousness of each condition and support the disciplines
and services provided)

ICD-10-CM and symptom control rating for each condition.
Note that the sequencing of these ratings may not match the
sequencing of the diagnoses

Description

ICD-10-CM / Symptom Control Rating

(M1021) Primary Diagnosis

V, W, X, Y codes NOT allowed

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

a.
a.
(M1023) Other Diagnoses

All ICD-10–CM codes allowed
b.

⃞0 ⃞1 ⃞2 ⃞3 ⃞4

(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.

⃞

1 -

Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)

⃞

2 -

Diabetes Mellitus (DM)

⃞

3 -

None of the above

(M1030) Therapies the patient receives at home: (Mark all that apply.)

⃞

1 -

Intravenous or infusion therapy (excludes TPN)

⃞

2 -

Parenteral nutrition (TPN or lipids)

⃞

3 -

Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the

⃞

4 -

alimentary canal)
None of the above

OASIS-D1 – All Item Set
Effective XX/XX/XXXX
Centers for Medicare & Medicaid Services

Page 6 of 31

PATIENT HISTORY AND DIAGNOSES, continued
(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for
hospitalization? (Mark all that apply.)

⃞

1 -

History of falls (2 or more falls – or any fall with an injury – in the past 12 months)

⃞

2 -

Unintentional weight loss of a total of 10 pounds or more in the past 12 months

⃞

3 -

Multiple hospitalizations (2 or more) in the past 6 months

⃞

4 -

Multiple emergency department visits (2 or more) in the past 6 months

⃞

5 -

Decline in mental, emotional, or behavioral status in the past 3 months

⃞

6 -

Reported or observed history of difficulty complying with any medical instructions (for example,
medications, diet, exercise) in the past 3 months

⃞

7 -

Currently taking 5 or more medications

⃞

8 -

Currently reports exhaustion

⃞

9 -

Other risk(s) not listed in 1 - 8

⃞

10 -

None of the above

(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?

Enter Code

0
1

(M1046)

Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year’s flu
season?

Enter Code

1
2
3
4
5
6
7
8

No [Go to M1051]
Yes

Yes; received from your agency during this episode of care (SOC/ROC to
Transfer/Discharge)
Yes; received from your agency during a prior episode of care (SOC/ROC to
Transfer/Discharge)
Yes; received from another health care provider (for example, physician, pharmacist)
No; patient offered and declined
No; patient assessed and determined to have medical contraindication(s)
No; not indicated – patient does not meet age/condition guidelines for influenza vaccine
No; inability to obtain vaccine due to declared shortage
No; patient did not receive the vaccine due to reasons other than those listed in
responses 4-7.

(M1051)

Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination (for
example, pneumovax)?

Enter Code

0
1

(M1056)

Reason Pneumococcal Vaccine not received: If patient has never received the
pneumococcal vaccination (for example, pneumovax), state reason:

Enter Code

1
2
3
4

No
Yes [Go to M2005 at TRN; Go to M1242 at DC]

Offered and declined
Assessed and determined to have medical contraindication(s)
Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine
None of the above

OASIS-D1– All Item Set
Effective XX/XX/XXXX
Centers for Medicare & Medicaid Services

Page 7 of 31

(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
inches

pounds

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.)

LIVING ARRANGEMENTS
(M1100) Patient Living Situation: Which of the following best describes the patient's residential circumstance and
availability of assistance? (Check one box only.)
Availability of Assistance

Living Arrangement

Around the
clock

Regular
daytime

Regular
nighttime

Occasional /
short-term
assistance

No
assistance
available

a. Patient lives alone

⃞ 01

⃞ 02

⃞ 03

⃞ 04

⃞ 05

b. Patient lives with other
person(s) in the home

⃞ 06

⃞ 07

⃞ 08

⃞ 09

⃞ 10

c. Patient lives in congregate
situation (for example, assisted
living, residential care home)

⃞ 11

⃞ 12

⃞ 13

⃞ 14

⃞ 15

SENSORY STATUS
(M1200)

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

Enter Code

0
1
2

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.

(M1242)

Frequency of Pain Interfering with patient's activity or movement:

Enter Code

0
1
2
3
4

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

OASIS-D1 – All Item Set
Effective XX/XX/XXXX
Centers for Medicare & Medicaid Services

Page 8 of 31

INTEGUMENTARY STATUS
(M1306)

Does this patient have at least one Unhealed Pressure Ulcer/Injury at Stage 2 or Higher or
designated as Unstageable? (Excludes Stage 1 pressure injuries and all healed pressure
ulcers/injuries)

Enter Code

0
1

(M1307)

The Oldest Stage 2 Pressure Ulcer that is present at discharge: (Excludes healed Stage 2
pressure ulcers)

Enter Code

1
2

No [Go to M1322 at SOC/ROC/FU; Go to M1324 at DC]
Yes

Was present at the most recent SOC/ROC assessment
Developed since the most recent SOC/ROC assessment. Record date pressure ulcer first
identified:
/

month
day
year
No Stage 2 pressure ulcers are present at discharge

SOC/ROC
(M1311) Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage

Enter
Number

A1. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink
wound bed, without slough. May also present as an intact or open/ruptured blister.
Number of Stage 2 pressure ulcers
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
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
D1. Unstageable: Non-removable dressing/device: Known but not stageable due to nonremovable dressing/device
Number of unstageable pressure ulcers/injuries due to non-removable dressing/device
E1. Unstageable: Slough and/or eschar: Known but not stageable due to coverage of wound bed
by slough and/or eschar
Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or
eschar
F1. Unstageable: Deep tissue injury
Number of unstageable pressure injuries presenting as deep tissue injury

OASIS-D1 – All Item Set
Effective XX/XX/XXXX
Centers for Medicare & Medicaid Services

Page 9 of 31

Follow-Up
Enter
Number

OASIS-D1 – All Item Set
Effective XX/XX/XXXX
Centers for Medicare & Medicaid Services

Page 10 of 31

INTEGUMENTARY STATUS, continued
Discharge
Enter
Number

(M1311) Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
A1. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink
wound bed, without slough. May also present as an intact or open/ruptured blister.
Number of Stage 2 pressure ulcers
[If 0 – Go to M1311B1, Stage 3]
A2. Number of these Stage 2 pressure ulcers that were present at most recent SOC/ROC
– enter how many were noted at the time of 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
[If 0 – Go to M1311C1, Stage 4]
B2. Number of these Stage 3 pressure ulcers that were present at most recent SOC/ROC
– enter how many were noted at the time of 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
[If 0 – Go to M1311D1, Unstageable: Non-removable dressing/device]
C2. Number of these Stage 4 pressure ulcers that were present at most recent SOC/ROC
– enter how many were noted at the time of most recent SOC/ROC
D1. Unstageable: Non-removable dressing/device: Known but not stageable due to nonremovable dressing/device
Number of unstageable pressure ulcers/injuries due to non-removable dressing/device
[If 0 – Go to M1311E1, Unstageable: Slough and/or eschar]
D2. Number of these unstageable pressure ulcers/injuries that were present at most recent
SOC/ROC
– enter how many were noted at the time of 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
Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or
eschar
[If 0 – Go to M1311F1, Unstageable: Deep tissue injury]
E2. Number of these unstageable pressure ulcers that were present at most recent SOC/ROC
– enter how many were noted at the time of most recent SOC/ROC
F1. Unstageable: Deep tissue injury
Number of unstageable pressure injuries presenting as deep tissue injury
[If 0 – Go to M1324]
F2. Number of these unstageable pressure injuries that were present at most recent
SOC/ROC
– enter how many were noted at the time of most recent SOC/ROC

OASIS-D1 – All Item Set
Effective XX/XX/XXXX
Centers for Medicare & Medicaid Services

Page 11 of 31

(M1322)

Current Number of Stage 1 Pressure Injuries: Intact skin with non-blanchable redness of a
localized area usually over a bony prominence. Darkly pigmented skin may not have a visible
blanching; in dark skin tones only it may appear with persistent blue or purple hues.

Enter Code

0
1
2
3
4 or more

(M1324)

Stage of Most Problematic Unhealed Pressure Ulcer/Injury that is Stageable: (Excludes
pressure ulcer/injury that cannot be staged due to a non-removable dressing/device, coverage of
wound bed by slough and/or eschar, or deep tissue injury.)

Enter Code

1
2
3
4
NA

(M1330)

Does this patient have a Stasis Ulcer?

Enter Code

0
1
2
3

(M1332)

Current Number of Stasis Ulcer(s) that are Observable:

Enter Code

1
2
3
4

(M1334)

Status of Most Problematic Stasis Ulcer that is Observable:

Enter Code

1
2
3

(M1340)

Does this patient have a Surgical Wound?

Enter Code

0
1
2

(M1342)

Status of Most Problematic Surgical Wound that is Observable

Enter Code

0
1
2
3

Stage 1
Stage 2
Stage 3
Stage 4
Patient has no pressure ulcers/injuries or no stageable pressure ulcers/injuries
No [Go to M1340]
Yes, patient has BOTH observable and unobservable stasis ulcers
Yes, patient has observable stasis ulcers ONLY
Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to nonremovable dressing/device) [Go to M1340]
One
Two
Three
Four or more
Fully granulating
Early/partial granulation
Not healing
No [Go to M1400]
Yes, patient has at least one observable surgical wound
Surgical wound known but not observable due to non-removable dressing/device [Go to M1400]
Newly epithelialized
Fully granulating
Early/partial granulation
Not healing

OASIS-D1 – All Item Set
Effective XX/XX/XXXX
Centers for Medicare & Medicaid Services

Page 12 of 31

RESPIRATORY STATUS
(M1400)

When is the patient dyspneic or noticeably Short of Breath?
0
1
2

Enter Code

3
4

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

ELIMINATION STATUS
(M1600)

Has this patient been treated for a Urinary Tract Infection in the past 14 days?

Enter Code

0
1
NA
UK

No
Yes
Patient on prophylactic treatment
Unknown [Omit “UK” option on DC]

(M1610)

Urinary Incontinence or Urinary Catheter Presence:

Enter Code

0
1
2

No incontinence or catheter (includes anuria or ostomy for urinary drainage)
Patient is incontinent
Patient requires a urinary catheter (specifically: external, indwelling, intermittent, or
suprapubic)

(M1620)

Bowel Incontinence Frequency:

Enter Code

0
1
2
3
4
5
NA
UK

(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?

Enter Code

0
1
2

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 [Omit “UK” option on FU, DC]

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.

OASIS-D1 – All Item Set
Effective XX/XX/XXXX
Centers for Medicare & Medicaid Services

Page 13 of 31

NEURO/EMOTIONAL/BEHAVIORAL STATUS
(M1700)
Enter Code

Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation,
comprehension, concentration, and immediate memory for simple commands.
0
1
2

3
4
(M1710)
Enter Code

(M1720)
Enter Code

(M1730)
Enter Code

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 (for example, 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.

When Confused (Reported or Observed Within the Last 14 Days):
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

When Anxious (Reported or Observed Within the Last 14 Days):
0
1
2
3
NA

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

Depression Screening: Has the patient been screened for depression, using a standardized,
validated depression screening tool?
0
1

No
Yes, patient was screened using the PHQ-2©* scale.
Instructions for this two-question tool: Ask patient: “Over the last two weeks, how often
have you been bothered by any of the following problems?”

PHQ-2©*

2
3

Little interest or pleasure
in doing things

Feeling down,
depressed, or hopeless?

Not at all
0-1 day

Several
days
2-6 days

More than
half of the
days
7-11 days

⃞0

⃞1

⃞2

⃞0

⃞1

⃞2

Nearly
NA
every day Unable to
12-14 days respond
⃞3
⃞3

⃞ NA
⃞ NA

Yes, patient was screened with a different standardized, validated assessment and the
patient meets criteria for further evaluation for depression.
Yes, patient was screened with a different standardized, validated assessment and the
patient does not meet criteria for further evaluation for depression.
*Copyright© Pfizer Inc. All rights reserved. Reproduced with permission.

OASIS-D1 – All Item Set
Effective XX/XX/XXXX
Centers for Medicare & Medicaid Services

Page 14 of 31

(M1740) Cognitive, behavioral, and psychiatric symptoms that are demonstrated at least once a week
(Reported or Observed): (Mark all that apply.)

⃞

1 -

Memory deficit: failure to recognize familiar persons/places, inability to recall events of past 24
hours, significant memory loss so that supervision is required

⃞

2 -

Impaired decision-making: failure to perform usual ADLs or IADLs, inability to appropriately stop

⃞

3 -

Verbal disruption: yelling, threatening, excessive profanity, sexual references, etc.

⃞

4 -

Physical aggression: aggressive or combative to self and others (for example, hits self, throws

activities, jeopardizes safety through actions

objects, punches, dangerous maneuvers with wheelchair or other objects)

⃞

5 -

Disruptive, infantile, or socially inappropriate behavior (excludes verbal actions)

⃞

6 -

Delusional, hallucinatory, or paranoid behavior

⃞

7 -

None of the above behaviors demonstrated

(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.

Enter Code

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

ADL/IADLs
(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).

Enter Code

0
1
2
3

(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:

Enter Code

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.

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.

(M1820)

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

Enter Code

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.

OASIS-D1 – All Item Set
Effective XX/XX/XXXX
Centers for Medicare & Medicaid Services

Page 15 of 31

ADL/IADLs, continued
(M1830)

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

Enter Code

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 intermittent 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.
Unable to use the shower or tub, but able to bathe self independently with or without the use of
devices at the sink, in chair, or on commode.
Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in
bedside chair, or on commode, with the assistance or supervision of another person.
Unable to participate effectively in bathing and is bathed totally by another person.

(M1840)

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

Enter Code

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.

(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.

Enter Code

0
1
2
3

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

(M1850)

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

Enter Code

0
1
2
3
4
5

Able to independently transfer.
Able to transfer with minimal human assistance or with use of an assistive device.
Able to bear weight and pivot during the transfer process but unable to transfer self.
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.

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Effective XX/XX/XXXX
Centers for Medicare & Medicaid Services

Page 16 of 31

ADL/IADLs, continued
(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.

Enter Code

0
1
2

3
4
5
6

Able to independently walk on even and uneven surfaces and negotiate stairs with or without
railings (specifically: needs no human assistance or assistive device).
With the use of a one-handed device (for example, cane, single crutch, hemi-walker), able to
independently walk on even and uneven surfaces and negotiate stairs with or without railings.
Requires use of a two-handed device (for example, walker or crutches) to walk alone on a
level surface and/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.

(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.

Enter Code

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.

(M1910)

Has this patient had a multi-factor Falls Risk Assessment using a standardized, validated
assessment tool?

Enter Code

0
1
2

No.
Yes, and it does not indicate a risk for falls.
Yes, and it does indicate a risk for falls.

OASIS-D1 – All Item Set
Effective XX/XX/XXXX
Centers for Medicare & Medicaid Services

Page 17 of 31

MEDICATIONS
(M2001)

Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant
medication issues?

Enter Code

0
1
9

(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?

Enter Code

0
1

(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?

Enter Code

0
1
9

(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?

Enter Code

0
1
NA

(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?

Enter Code

0
1
NA

(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.)

Enter Code

0
1

2
3
NA

No – No issues found during review [Go to M2010]
Yes – Issues found during review
NA – Patient is not taking any medications [Go to M2102]

No
Yes

No
Yes
NA – There were no potential clinically significant medication issues identified since SOC/ROC
or patient is not taking any medications

No
Yes
Patient not taking any high-risk drugs OR patient/caregiver fully knowledgeable about special
precautions associated with all high-risk medications

No
Yes
Patient not taking any drugs

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) another person develops a drug diary or chart.
Able to take medication(s) at the correct times if given reminders by another person at the
appropriate times
Unable to take medication unless administered by another person.
No oral medications prescribed.

OASIS-D1 – All Item Set
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Centers for Medicare & Medicaid Services

Page 18 of 31

(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.

Enter Code

0
1

2
3
NA

Able to independently take the correct medication(s) and proper dosage(s) at the correct
times.
Able to take injectable medication(s) at the correct times if:
(a) individual syringes are prepared in advance by another person; OR
(b) another person develops a drug diary or chart.
Able to take medication(s) at the correct times if given reminders by another person based on
the frequency of the injection
Unable to take injectable medication unless administered by another person.
No injectable medications prescribed.

CARE MANAGEMENT
SOC/ROC
(M2102)

Enter Code

Discharge
(M2102)

Enter Code

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.
a. ADL assistance (for example, transfer/ ambulation, bathing, dressing, toileting, eating/feeding)
0 No assistance needed –patient is independent or does not have needs in this area
1 Non-agency caregiver(s) currently provide assistance
2 Non-agency caregiver(s) need training/ supportive services to provide assistance
3 Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will
provide assistance
4 Assistance needed, but no non-agency caregiver(s) available
c. Medication administration (for example, oral, inhaled or injectable)
0 No assistance needed –patient is independent or does not have needs in this area
1 Non-agency caregiver(s) currently provide assistance
2 Non-agency caregiver(s) need training/ supportive services to provide assistance
3 Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will
provide assistance
4 Assistance needed, but no non-agency caregiver(s) available
d. Medical procedures/ treatments (for example, changing wound dressing, home exercise
program)
0 No assistance needed –patient is independent or does not have needs in this area
1 Non-agency caregiver(s) currently provide assistance
2 Non-agency caregiver(s) need training/ supportive services to provide assistance
3 Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will
provide assistance
4 Assistance needed, but no non-agency caregiver(s) available
f. Supervision and safety (for example, due to cognitive impairment)
0 No assistance needed –patient is independent or does not have needs in this area
1 Non-agency caregiver(s) currently provide assistance
2 Non-agency caregiver(s) need training/ supportive services to provide assistance
3 Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will
provide assistance
4 Assistance needed, but no non-agency caregiver(s) available

OASIS-D1 – All Item Set
Effective XX/XX/XXXX
Centers for Medicare & Medicaid Services

Page 19 of 31

THERAPY NEED AND PLAN OF CARE
(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.)

() 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.
EMERGENT CARE
(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)?

Enter Code

0
1
2
UK

No [Go to M2401]
Yes, used hospital emergency department WITHOUT hospital admission
Yes, used hospital emergency department WITH hospital admission
Unknown [Go to M2401]

(M2310) Reason for Emergent Care: For what reason(s) did the patient seek and/or receive emergent care (with or
without hospitalization)? (Mark all that apply.)

⃞

1 -

Improper medication administration, adverse drug reactions, medication side effects, toxicity,
anaphylaxis

⃞ 10 - Hypo/Hyperglycemia, diabetes out of control
⃞ 19 - Other than above reasons
⃞ UK - Reason unknown

OASIS-D1 – All Item Set
Effective XX/XX/XXXX
Centers for Medicare & Medicaid Services

Page 20 of 31

DATA ITEMS COLLECTED AT INPATIENT FACILITY ADMISSION OR AGENCY
DISCHARGE ONLY
(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?
No

Yes

Diabetic foot care including monitoring
for the presence of skin lesions on the
lower extremities and
patient/caregiver education on proper
foot care

Plan / Intervention

⃞0

⃞1

Not Applicable
⃞NA

Patient is not diabetic or is missing lower
legs due to congenital or acquired
condition (bilateral amputee).

Falls prevention interventions

⃞0

⃞1

⃞NA

Every standardized, validated multi-factor
fall risk assessment conducted at or since
the most recent SOC/ROC assessment
indicates the patient has no risk for falls.

Depression intervention(s) such as
medication, referral for other
treatment, or a monitoring plan for
current treatment

⃞0

⃞1

⃞NA

Patient has no diagnosis of depression
AND every standardized, validated
depression screening conducted at or
since the most recent SOC/ROC
assessment indicates the patient has:
1) no symptoms of depression; or 2) has
some symptoms of depression but does
not meet criteria for further evaluation of
depression based on screening tool used.

Intervention(s) to monitor and mitigate
pain

⃞0

⃞1

⃞NA

Every standardized, validated pain
assessment conducted at or since the
most recent SOC/ROC assessment
indicates the patient has no pain.

Intervention(s) to prevent pressure
ulcers

⃞0

⃞1

⃞NA

Every standardized, validated pressure
ulcer risk assessment conducted at or
since the most recent SOC/ROC
assessment indicates the patient is not at
risk of developing pressure ulcers.

Pressure ulcer treatment based on
principles of moist wound healing

⃞0

⃞1

⃞NA

Patient has no pressure ulcers OR has no
pressure ulcers for which moist wound
healing is indicated.

(M2410)

To which Inpatient Facility has the patient been admitted?

Enter Code

1
2
3
4
NA

(M2420)

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

Enter Code

1
2
3
4
UK

Hospital
Rehabilitation facility
Nursing home
Hospice
No inpatient facility admission [Omit “NA” option on TRN]

Patient remained in the community (without formal assistive services)
Patient remained in the community (with formal assistive services)
Patient transferred to a non-institutional hospice
Unknown because patient moved to a geographic location not served by this agency
Other unknown

(M0906) Discharge/Transfer/Death Date: Enter the date of the discharge, transfer, or death (at home) of the
patient.

/
month

/
day

year

OASIS-D1 – All Item Set
Effective XX/XX/XXXX
Centers for Medicare & Medicaid Services

Page 21 of 31

Section GG

Functional Abilities and Goals

GG0100. Prior Functioning: Everyday Activities: Indicate the patient’s usual ability with everyday activities prior
to the current illness, exacerbation, or injury.
Coding:
3. Independent – Patient completed the
activities by him/herself, with or without
an assistive device, with no assistance
from a helper.
2. Needed Some Help – Patient needed
partial assistance from another person to
complete activities.
1. Dependent – A helper completed the
activities for the patient.
8. Unknown
9. Not Applicable

↓ Enter Codes in Boxes
A.

Self Care: Code the patient’s need for assistance with
bathing, dressing, using the toilet, or eating prior to the
current illness, exacerbation, or injury.

Indoor Mobility (Ambulation): Code the patient’s need
for assistance with walking from room to room (with or
without a device such as cane, crutch or walker) prior to
the current illness, exacerbation, or injury.

Stairs: Code the patient’s need for assistance with
internal or external stairs (with or without a device such
as cane, crutch, or walker) prior to the current illness,
exacerbation or injury.

Functional Cognition: Code the patient’s need for
assistance with planning regular tasks, such as shopping
or remembering to take medication prior to the current
illness, exacerbation, or injury.

GG0110. Prior Device Use. Indicate devices and aids used by the patient prior to the current illness,
exacerbation, or injury.

↓ Check all that apply
A.

Manual wheelchair

Motorized wheelchair and/or scooter

Mechanical lift

Walker

Orthotics/Prosthetics

None of the above

OASIS-D1 – All Item Set
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Centers for Medicare & Medicaid Services

Page 22 of 31

Section GG: Self-Care
SOC/ROC
GG0130. Self-Care
Code the patient’s usual performance at SOC/ROC for each activity using the 6-point scale. If activity was
not attempted at SOC/ROC, code the reason. Code the patient’s discharge goal(s) using the 6-point scale.
Use of codes 07, 09, 10 or 88 is permissible to code discharge goal(s).
Coding:
Safety and Quality of Performance – If helper assistance is required because patient’s performance is unsafe or
of poor quality, score according to amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent – Patient completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance – Helper sets up or cleans up; patient completes activity. Helper assists only
prior to or following the activity.
04. Supervision or touching assistance – Helper provides verbal cues and/or touching/steadying and/or contact
guard assistance as patient completes activity. Assistance may be provided throughout the activity or
intermittently.
03. Partial/moderate assistance – Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk
or limbs, but provides less than half the effort.
02. Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or
limbs and provides more than half the effort.
01. Dependent – Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the
assistance of 2 or more helpers is required for the patient to complete the activity.
If activity was not attempted, code reason:
07. Patient refused
09. Not applicable – Not attempted and the patient did not perform this activity prior to the current illness,
exacerbation or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical conditions or safety concerns
1.
SOC/ROC
Performance

2.
Discharge
Goal

↓ Enter Codes in Boxes ↓
A.

Eating: The ability to use suitable utensils to bring food and/or liquid to the
mouth and swallow food and/or liquid once the meal is placed before the
patient.

Oral Hygiene: The ability to use suitable items to clean teeth. Dentures (if
applicable): The ability to remove and replace dentures from and to the mouth,
and manage equipment for soaking and rinsing them.

Toileting Hygiene: The ability to maintain perineal hygiene, adjust clothes
before and after voiding or having a bowel movement. If managing an ostomy,
include wiping the opening but not managing equipment.

Shower/bathe self: The ability to bathe self, including washing, rinsing, and
drying self (excludes washing of back and hair). Does not include transferring
in/out of tub/shower

Upper body dressing: The ability to dress and undress above the waist;
including fasteners, if applicable.

G. Lower body dressing: The ability to dress and undress below the waist,
including fasteners; does not include footwear.
H.

Putting on/taking off footwear: The ability to put on and take off socks and
shoes or other footwear that is appropriate for safe mobility; including
fasteners, if applicable.

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Effective XX/XX/XXXX
Centers for Medicare & Medicaid Services

Page 23 of 31

Follow-Up
GG0130. Self-Care
Code the patient’s usual performance at Follow-Up for each activity using the 6-point scale. If activity was
not attempted at Follow-Up, code the reason.
Coding:
Safety and Quality of Performance – If helper assistance is required because patient’s performance is unsafe or
of poor quality, score according to amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent – Patient completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance – Helper sets up or cleans up; patient completes activity. Helper assists only
prior to or following the activity.
04. Supervision or touching assistance – Helper provides verbal cues and/or touching/steadying and/or contact
guard assistance as patient completes activity. Assistance may be provided throughout the activity or
intermittently.
03. Partial/moderate assistance – Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk
or limbs, but provides less than half the effort.
02. Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or
limbs and provides more than half the effort.
01. Dependent – Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the
assistance of 2 or more helpers is required for the patient to complete the activity.
If activity was not attempted, code reason:
07. Patient refused
09. Not applicable – Not attempted and the patient did not perform this activity prior to the current illness,
exacerbation or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical conditions or safety concerns
4.
Follow-Up
Performance
Enter Codes
in Boxes
A.

Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and
swallow food and/or liquid once the meal is placed before the patient.

Oral Hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The
ability to insert and remove dentures into and from the mouth, and manage denture
soaking and rinsing with use of equipment.

Toileting Hygiene: The ability to maintain perineal hygiene, adjust clothes before and
after voiding or having a bowel movement. If managing an ostomy, include wiping the
opening but not managing equipment.

OASIS-D1 – All Item Set
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Page 24 of 31

Discharge
GG0130. Self-Care
Code the patient’s usual performance at Discharge for each activity using the 6-point scale. If activity was
not attempted at Discharge, code the reason.
Coding:
Safety and Quality of Performance – If helper assistance is required because patient’s performance is unsafe or
of poor quality, score according to amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent – Patient completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance – Helper sets up or cleans up; patient completes activity. Helper assists only
prior to or following the activity.
04. Supervision or touching assistance – Helper provides verbal cues and/or touching/steadying and/or contact
guard assistance as patient completes activity. Assistance may be provided throughout the activity or
intermittently.
03. Partial/moderate assistance – Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk
or limbs, but provides less than half the effort.
02. Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or
limbs and provides more than half the effort.
01. Dependent – Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the
assistance of 2 or more helpers is required for the patient to complete the activity.
If activity was not attempted, code reason:
07. Patient refused
09. Not applicable – Not attempted and the patient did not perform this activity prior to the current illness,
exacerbation or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical conditions or safety concerns
3.
Discharge
Performance
Enter Codes
in Boxes
A.

Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and
swallow food and/or liquid once the meal placed before the patient.

Toileting Hygiene: The ability to maintain perineal hygiene, adjust clothes before and
after voiding or having a bowel movement. If managing an ostomy, include wiping the
opening but not managing equipment.

Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self
(excludes washing of back and hair). Does not include transferring in/out of tub/shower.

Upper body dressing: The ability to dress and undress above the waist; including
fasteners, if applicable.

G. Lower body dressing: The ability to dress and undress below the waist, including
fasteners; does not include footwear.
H.

Putting on/taking off footwear: The ability to put on and take off socks and shoes or
other footwear that is appropriate for safe mobility; including fasteners, if applicable.

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Page 25 of 31

Section GG: Mobility
SOC/ROC
GG0170. Mobility
Code the patient’s usual performance at SOC/ROC for each activity using the 6-point scale. If activity was
not attempted at SOC/ROC, code the reason. Code the patient’s discharge goal(s) using the 6-point scale.
Use of codes 07, 09, 10 or 88 is permissible to code discharge goal(s).
Coding:
Safety and Quality of Performance – If helper assistance is required because patient’s performance is unsafe or
of poor quality, score according to amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent – Patient completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance – Helper sets up or cleans up; patient completes activity. Helper assists only
prior to or following the activity.
04. Supervision or touching assistance – Helper provides verbal cues and/or touching/steadying and/or
contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or
intermittently.
03. Partial/moderate assistance – Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk
or limbs, but provides less than half the effort.
02. Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or
limbs and provides more than half the effort.
01. Dependent – Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the
assistance of 2 or more helpers is required for the patient to complete the activity.
If activity was not attempted, code reason:
07. Patient refused
09. Not applicable – Not attempted and the patient did not perform this activity prior to the current illness,
exacerbation or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical conditions or safety concerns
1.
SOC/ROC
Performance

2.
Discharge
Goal

↓ Enter Codes in Boxes ↓
A.

Roll left and right: The ability to roll from lying on back to left and right side,
and return to lying on back on the bed.

Sit to lying: The ability to move from sitting on side of bed to lying flat on the
bed.

Lying to sitting on side of bed: The ability to 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.

Sit to stand: The ability to come to a standing position from sitting in a chair,
wheelchair, or on the side of the bed.

Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a
chair (or wheelchair).

Toilet transfer: The ability to get on and off a toilet or commode.

G. Car Transfer: The ability to transfer in and out of a car or van on the
passenger side. Does not include the ability to open/close door or fasten seat
belt.
I.

Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room,
corridor, or similar space.
If SOC/ROC performance is coded 07, 09, 10 or 88, skip to GG0170M, 1 step
(curb)

Walk 50 feet with two turns: Once standing, the ability to walk 50 feet and
make two turns.

OASIS-D1 – All Item Set
Effective XX/XX/XXXX
Centers for Medicare & Medicaid Services

Page 26 of 31

Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor
or similar space.

Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven
or sloping surfaces (indoor or outdoor), such as turf or gravel.

M. 1 step (curb): The ability to go up and down a curb and/or up and down one
step.
If SOC/ROC performance is coded 07, 09, 10 or 88, skip to GG0170P,
Picking up object.
N.

4 steps: The ability to go up and down four steps with or without a rail.
If SOC/ROC performance is coded 07, 09, 10 or 88, skip to GG0170P,
Picking up object.

O. 12 steps: The ability to go up and down 12 steps with or without a rail.
P.

Picking up object: The ability to bend/stoop from a standing position to pick
up a small object, such as a spoon, from the floor.
Q.

Does patient use wheelchair and/or scooter?
0. No → Skip GG0170R, GG0170RR1, GG0170S, and GG0170SS1.
1. Yes → Continue to GG0170R, Wheel 50 feet with two turns.

R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability
to wheel at least 50 feet and make two turns.
RR1. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized
S.

Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at
least 150 feet in a corridor or similar space.
SS1. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized

OASIS-D1 – All Item Set
Effective XX/XX/XXXX
Centers for Medicare & Medicaid Services

Page 27 of 31

Follow-Up
GG0170. Mobility
Code the patient’s usual performance at Follow-Up for each activity using the 6-point scale. If activity was
not attempted at Follow-Up code the reason.
Coding:
Safety and Quality of Performance – If helper assistance is required because patient’s performance is unsafe or
of poor quality, score according to amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent – Patient completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance – Helper sets up or cleans up; patient completes activity. Helper assists only
prior to or following the activity.
04. Supervision or touching assistance – Helper provides verbal cues and/or touching/steadying and/or contact
guard assistance as patient completes activity. Assistance may be provided throughout the activity or
intermittently.
03. Partial/moderate assistance – Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk
or limbs, but provides less than half the effort.
02. Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or
limbs and provides more than half the effort.
01. Dependent – Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the
assistance of 2 or more helpers is required for the patient to complete the activity.
If activity was not attempted, code reason:
07. Patient refused
09. Not applicable – Not attempted and the patient did not perform this activity prior to the current illness,
exacerbation or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical conditions or safety concerns
4.
Follow-Up
Performance
Enter Codes
in Boxes
A. Roll left and right: The ability to roll from lying on back to left and right side, and return to
lying on back on the bed.
B. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.
C.
D.
E.
F.
I.

Lying to sitting on side of bed: The ability to 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.
Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or
on the side of the bed.
Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or
wheelchair).
Toilet transfer: The ability to get on and off a toilet or commode.
Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or
similar space.
If Follow-Up performance is coded 07, 09, 10 or 88 → skip to GG0170M, 1 step (curb).
Walk 50 feet with two turns: Once standing, the ability to walk 50 feet and make two turns.

Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping
surfaces (indoor or outdoor), such as turf or gravel.
M. 1 step (curb): The ability to go up and down a curb and/or up and down one step.
If Follow-up performance is coded 07, 09, 10 or 88, skip to GG0170Q, Does patient use
wheelchair and/or scooter?
N. 4 steps: The ability to go up and down four steps with or without a rail.

Q. Does patient use wheelchair and/or scooter?
0. No →Skip GG0170R
1. Yes → Continue to GG0170R, Wheel 50 feet with two turns.
Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at
least 50 feet and make two turns.

OASIS-D1 – All Item Set
Effective XX/XX/XXXX
Centers for Medicare & Medicaid Services

Page 28 of 31

Discharge
GG0170. Mobility
Code the patient’s usual performance at Discharge for each activity using the 6-point scale. If activity was
not attempted at Discharge, code the reason.
Coding:
Safety and Quality of Performance – If helper assistance is required because patient’s performance is unsafe or
of poor quality, score according to amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent – Patient completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance – Helper sets up or cleans up; patient completes activity. Helper assists only
prior to or following the activity.
04. Supervision or touching assistance – Helper provides verbal cues and/or touching/steadying and/or contact
guard assistance as patient completes activity. Assistance may be provided throughout the activity or
intermittently.
03. Partial/moderate assistance – Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk
or limbs, but provides less than half the effort.
02. Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or
limbs and provides more than half the effort.
01. Dependent – Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the
assistance of 2 or more helpers is required for the patient to complete the activity.
If activity was not attempted, code reason:
07. Patient refused
09. Not applicable – Not attempted and the patient did not perform this activity prior to the current illness,
exacerbation or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical conditions or safety concerns
3.
Discharge
Performance
Enter Codes
in Boxes
A.

Roll left and right: The ability to roll from lying on back to left and right side, and return to
lying on back on the bed.

Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.

Lying to sitting on side of bed: The ability to 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.

Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or
on the side of the bed.

Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or
wheelchair).

Toilet transfer: The ability to get on and off a toilet or commode.

G. Car Transfer: The ability to transfer in and out of a car or van on the passenger side. Does
not include the ability to open/close door or fasten seat belt.
I.

Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or
similar space.
If Discharge performance is coded 07, 09, 10 or 88, skip to GG0170M, 1 step (curb).

Walk 50 feet with two turns: Once standing, the ability to walk 50 feet and make two
turns.

Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar
space.

Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping
surfaces (indoor or outdoor), such as turf or gravel.

M. 1 step (curb): The ability to go up and down a curb and/or up and down one step.
If Discharge performance is coded 07, 09, 10 or 88, skip to GG0170P, Picking up object.
OASIS-D1 – All Item Set
Effective XX/XX/XXXX
Centers for Medicare & Medicaid Services

Page 29 of 31

4 steps: The ability to go up and down four steps with or without a rail.
If Discharge performance is coded 07, 09, 10 or 88, skip to GG0170P, Picking up object.

O. 12 steps: The ability to go up and down 12 steps with or without a rail.
P.

Picking up object: The ability to bend/stoop from a standing position to pick up a small
object, such as a spoon, from the floor.
Q. Does patient use wheelchair and/or scooter?
0. No → Skip to J1800 Any falls since SOC/ROC, whichever is more recent.
1. Yes → Continue to GG0170R, Wheel 50 feet with two turns.

Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at
least 50 feet and make two turns.
RR3. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized

Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in
a corridor or similar space.
SS3. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized

OASIS-D1 – All Item Set
Effective XX/XX/XXXX
Centers for Medicare & Medicaid Services

Page 30 of 31

Section J: Health Conditions
J1800.

Any Falls Since SOC/ROC, whichever is more recent

Enter Code

Has the patient had any falls since SOC/ROC, whichever is more recent?
0. No → Skip J1900
1. Yes → Continue to J1900, Number of Falls Since SOC/ROC, whichever is more recent

J1900.

Number of Falls Since SOC/ROC, whichever is more recent

CODING:
0. None
1. One
2. Two or
more

↓ Enter Codes in Boxes.
A.

No injury: No evidence of any injury is noted on physical assessment by the nurse or
primary care clinician; no complaints of pain or injury by the patient; no change in the
patient's behavior is noted after the fall

Injury (except major): Skin tears, abrasions, lacerations, superficial bruises,
hematomas and sprains; or any fall-related injury that causes the patient to complain
of pain

Major injury: Bone fractures, joint dislocations, closed head injuries with altered
consciousness, subdural hematoma

OASIS-D1 – All Item Set
Effective XX/XX/XXXX
Centers for Medicare & Medicaid Services

Page 31 of 31

File Type	application/pdf
File Title	Attachment B OASIS-D1 All Items
Subject	OASIS, OASIS-D1, 2020
Author	Centers for Medicare and Medicaid Services
File Modified	2021-07-30
File Created	2018-12-17