• Combine observation, interview, and other relevant strategies to complete OASIS data items as needed (for example, it is acceptable to review the hospital discharge summary to identify inpatient procedures and diagnoses at start of care, or to examine the care notes to determine if an ordered intervention was implemented at transfer or discharge). However, when assessing physiologic or functional health status, direct observation is the preferred strategy. • When an OASIS item refers to assistance, this means assistance from another person. Assistance is not limited to physical contact and can include verbal cues and/or supervision. • Complete OASIS items accurately and comprehensively and adhere to skip patterns. • Understand the definitions of words as used in the OASIS. • Follow rules included in the specific OASIS Item Guidance (Chapter 3 of the OASIS Guidance Manual). • Stay current with evolving CMS OASIS guidance updates. CMS may post updates to the Guidance Manual up to twice per year, and releases OASIS Q&As quarterly. • Only one clinician may take responsibility for accurately completing a comprehensive assessment. However, for all OASIS data items integrated within the comprehensive assessment, collaboration with the patient/client, caregivers, and other healthcare personnel, including the physician, pharmacist, and/or other agency staff, is appropriate and would not violate the one clinician convention. When collaboration is utilized, the assessing clinician is responsible for considering available input from these other sources and selecting the appropriate OASIS item response(s) within the appropriate time frame and consistent with data collection guidance. • The use of the term “specifically” means scoring of the item should be limited to only the circumstances listed. The use of “for example” means the clinician may consider other relevant circumstances or attributes when scoring the item. Conventions Specific to ADL/IADL Items • Report the patient’s/client’s physical and cognitive ability to perform a task. Do not report on the patient’s/client’s preference or willingness to perform a specified task. • The level of ability refers to the level of assistance (if any) that the patient/client requires to safely complete a specified task. • While the presence or absence of a caregiver may impact the way a patient/client carries out an activity, it does not impact the assessing clinician’s ability to assess the patient/client in order to determine and report the level of assistance that the patient/client requires to safely complete a task. • Understand what tasks are included and excluded in each item, and select the OASIS response based only on included tasks.
