Clinical record review in the past several weeks has revealed that my clients have greatly improved their ICD-9 coding. It’s really no surprise. Coding classes are offered regularly and there are many great services out there to assist agencies with coding. And coding is critical to home health PPS. No one can deny that.
But what I have been seeing repeatedly is clinical records reflecting very high clinical scores and almost non-existent functional scores. It’s as though once the diagnosis coding is correct, nothing further in the OASIS data set is examined. This morning, for instance, I reviewed a report of a patient who has severe visual impairment, is short of breath with minimal exertion and has diabetic neuropathy. But, as it turns out, this patient is safe to dress by herself, including retrieving her own clothes. And by divine intervention, it is safe for her to bathe and toilet independently.
I have not looked at this patient. Nor would I mention this patient if this wasn’t so very typical of what I have been seeing in charts. And this is costing agencies!
Many nurses think that because a patient is forced by circumstance to perform these activities of daily living that they are able to do so safely and independently. And yet, OASIS instructions are very clear in that safety should always be considered in responding to the OASIS functional domain questions.
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