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Posts tagged ‘OASIS-C’

3 Errors


I’ve been reviewing charts all week and the same errors keep showing up over and over again.  I know the nurses doing the charting and they are not as dimwitted as they may seem on paper.  In fact, I would wager a bet that the only nurses who have never made at least one of these errors has only a passing acquaintance with the truth.

Charting Bilateral Pedal Pulses on an Amputee

The same nurses who did this also charted on the surgical wound, the therapy the patient was receiving and otherwise did an excellent job of documenting.  So, why are they charting about pedal pulses on an amputee?  Because they are used to checking the box that says a patient has bilateral pulses. The same thing happens in M1030 which asks about therapies the patient is receiving at home and when they overlook an Ostomy in the OASIS questions.  My theory is that if you give a nurse a check box, it will be checked.

Charting Tip

When a patient does not meet the response you typically chart greater than 90 percent of the time, mark it when  you notice it.  Even if you do not have time to complete the entire document, respond to those questions that you may answer incorrectly at a later time out of habit.  Outsmart yourself so you don’t end up trying to explain to some board of nursing how you were able to find a pedal pulse in some other part of the body.

Underscoring Functional Limitations

Look at the question about ‘locomotion’.  Response 2 reads: 

Requires use of a two-handed device (e.g., 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.

This response is usually selected when a patient requires a walker and it may be correct but keep reading.  If the patient requires human supervision or assistance to negotiate stairs or steps or uneven surfaces, the correct response is 2.  This is true even of patients who do not require a walker.

Charting Tip

Mentally break this question in two. 

  • Does the patient need a two handed device? 
  • Can they negotiate stairs and uneven surfaces without human assistance or supervision?

Transferring

Most people think of transferring as moving from one place to the other.  In general terms, that’s close but OASIS gives us a very complicated and lengthy definition of transferring.  Here it is step by step (there should be an app for this one).

  • Begin with the patient in a supine position (laid out flat on their back)
  • The patient then gets to a position sitting on the side of the bed.  The methodology must be chosen by the patient  because there is an uncharacteristic lack of instructions in the manual.
  • The patient then stands and pivots. (I had entire tennis lessons which focused on pivoting.  If your patient is a retired tennis pro you might be in luck).
  • Then the patient sits.

But Wait!  That’s not all.

  • The patient must now be able to stand again
  • Pivot
  • Sit on the side of the bed
  • Somehow get flat on his back again.

Could there possibly be more to it than this?  Absolutely.  There are some patients who do not have a place to sit next to their bed.  Their instructions are even lengthier. 

  • Begin with the patient laid out flat again
  • The patient then gets to a position sitting on the side of the bed.
  • The patient then stands and pivots.
  • The patient safely proceeds to the place where he or she normally sits.  This may be the kitchen or the porch or the toilet.  The destination is not defined but I’m going to out on a limb and tell you that it does mean a seated position on the floor because they could not support their weight.
  • Then the patient sits.  I suspect that there may be a little pivoting involved here as well but the directions are not clear. 
  • The patient must now be able to stand again
  • The patient makes his or her way back to the bedroom as the return trip begins
  • Once again they pivot (Group and Individual Pivoting lessons are available from HCS)
  • Sit on the side of the bed
  • Somehow get flat on his back again.

Here’s the fun part.  If your patient typically gets up in the morning and goes outside on the porch to enjoy his coffee but requires help to make the distance, you can greatly improve your outcomes by….  wait for it…  putting a chair next to his bed.  There are some patients who because of shortness of breath, weakness from a recent injury or pain, just need to sit for a few minutes before continuing their journey to the great outdoors or wherever they sit.  Not only will your outcomes improve but a patient who previously had to wait on someone to help them get up is no longer trapped in the bed until someone has the time to get to them. 

What’s more, if you recall that the definition of the day in question refers to the 24 hours prior to and including the visit, you can still improve outcomes even if you put the chair in place on admit. 

Charting Tip

Print the list and keep it with you.   It is rather complicated.

That’s all for today folks but there is sadly more where that came from.  If you have never made any of these errors, it is probable that nobody is reviewing assessments at your agency.  One of the best investments is a data scrubbing program.  My personal favorite is Episode Master although I am angling to have the name changed to Episode Mistress.

Look for more next week.

Case Conferencing


When it comes to good patient care there is no substitute for case conferencing. In my years of experience, I have seen agencies who chose not to conduct a structured case conference, agencies who held a meeting where patients were discussed just long enough to meet minimum standards and I have seen agencies that make the absolute most out of a weekly or bi-monthly case conference. Guess which agencies do better overall?

With OASIS-C now a reality, there are even more reasons to conduct a thorough case conference that includes process measures. In doing so, discharge reviews will be much easier to perform.

These are some of the processes I’ve seen at various agencies over the years that make case conferencing more effective. Pick and choose those ones that you like and send us any other ideas we might not have heard.

  1. Prepare a list of patients up for recert in advance so that charts can be reviewed by the RN who will do the recertification visit.
  2. Invite all disciplines involved in care. I have seen some agencies where aides are not included. This is a critical mistake.
  3. Ensure that all the questions you want answered in case conference are addressed. You may want to make a short form or post the questions in the agency. That way the nurse who is reviewing the clinical record prior to case conference is aware of the information that she will be asked. Consider the following questions:
    1. Has the patient seen the doctor this episode and if so, why?
    2. Was any lab drawn? What are the abnormal results?
    3. Were there any medication changes?
    4. Was the patient taught on all medications?
    5. Did the patient go to the hospital at all? Why?
    6. Does the patient have heart failure? If so, what are the weight ranges?
    7. Does the patient have diabetes? What are the blood sugar ranges?
    8. Did any falls, injuries or other adverse events occur during the episode?
    9. Did the patient have a wound? Describe at beginning and end of episode. State wound care and any changes that occurred in the last episode.
    10. How was the patient’s pain managed? Were any interventions implemented with or without success?
  4. If a staff member is not able to attend, try to include them on the telephone.
  5. Get signatures of all attendees.

Or you could just pull the staff in from the field, feed them donuts and do the bare minimum to demonstrate compliance to the care coordination condition of participation. Either way, it costs whenever you bring field staff in for mandatory meetings. Why not get the most for your dollar?

Last Minute Questions


Over the last few days, I have been getting a lot of last minute OASIS questions as we are about to dive headfirst into the new dataset. Real quickly, let me address a couple of them in case you are also wondering.

First of all, the use of dataset begins January 1. That means if the response to M0090 (date assessment completed) includes ‘2009’, you will use the old dataset even if the episode begins in 2010. Many of my clients point out that this make no sense. Never mind all that right now. Just do it.

Secondly, when an OASIS-C begins with, “Since the previous OASIS assessment…..” the time period includes the actual prior assessment visit. For instance, if you found your patient to have pain on admission and you called for orders for therapy and the patient has been pain free ever since, you would include the interventions performed during the admission visit.

Finally, the ‘physician ordered plan of care’ discussed at length in M2250 means that the physician plan of care has been communicated to and ‘authorized’ by the physician. If the orders have been requested but not received then the plan of care is not considered to physician authorized.

This means that a one way fax to the doctor does not count. A cursory ‘okay’ by the office nurse will not suffice unless you are confident that she has relayed the message to the MD and she is communicating the MD’s message to you.

Again, sometimes, the answer will be, ‘No’.

The date that you receive the last piece of information that you require for the care planning is the date that should be reflected in M0090. Therefore if you do the admission on Monday and it isn’t until Wednesday that you hear back from the MD, M0090 will be whatever date Wednesday falls on. A lot of the timeliness will be at the mercy of physician cooperation. However, the MD’s will never sign off on anything timely if we get it to them late. Our processes will also be reflected in these questions.

And please don’t shoot the messenger.

Referral Contact


My fear for next week is a mental health crisis affecting all physicians referring to home health. In spite of every medication and therapy known to address tinnitus, our MD’s will be driven crazy by incessant ringing of the ears.

If you want to protect the sanity of your favorite referral sources and haven’t already done so, draft a fax template for medication and care plan review. For meds, it might read something like:

URGENT FAX:

Dear Dr. Bleaux:

We have reviewed Mr. Thibodeaux’s medications and have found the following issues that might affect his plan of care:

Tagamet and Cimetidine are both ordered for this patient. Can we have a clarification order for our care plan?

Leave room for the MD to make notes and sign/date his or her signature. Place your fax number prominently on the sheet.

The last line should read something like: BEST PRACTICES MANDATE THAT WE HAVE CLARIFICATION ON THIS POTENTIAL MEDICATION ERROR BEFORE THE END OF THE TOMORROW. Sooner is better. YOUR COOPERATION IS APPRECIATED BY US AND YOUR PATIENT!

Be sure to include all pertinent information about the patient including the date of birth since many physician offices use date of birth for patient identification. The easier that you make this process for the MD, the better your response will be.

Next, start tracking response times per physician. Make a copy of any fax that is returned later than the deadline. Share these faxes with your marketing staff so that physicians can be educated (beaten up) if they do not comply.

Remember, physician contact includes two way communication.  In order to document that the physician was contacted you must have verification of two way communication with the doctor.  Sending a fax is not enough.  Only when you receive a call back or return fax, have you met the criteria for responding Yes to MD contact within one calendar day.

Merry Christmas from WOCN


The long awaited guidance from WOCN is here.  Click below to read it now.  We have also save it under ‘Essential links’ on the sidebar to the left  for safe keeping and future reference. Let us know what you think of the new guidance below in the comments section below or email us.

GuidanceOASIS-C WOCN

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