OASIS Assessment

Patient Identification & Visit Metadata

• Patient Identifiers: [Full name], [DOB], [MRN], [Address], [Phone]
• Referral Source: [Hospital / Clinic / SNF / Self / Other: ____]
• Discipline: [SN / PT / OT / SLP / MSW / HHA]
• Assessment Timepoint: [SOC / ROC / Recert / Discharge] (Select one)
• Visit Date/Time: [Date], [Start time]–[End time] [Time zone] (Document time in/out)
• Clinician: [Name, credentials], [Signature], [Date]

Reason for Care & Diagnoses

• Primary Diagnosis: [ICD-10 description/code]
• Secondary Diagnoses: [List relevant conditions/codes]
• Recent Events/Hospitalizations: [Facility], [Dates], [Procedures/complications] (Only if applicable)
• Reason for Home-Health Admission: [Skilled need(s) and clinical indications]

Homebound Status Statement

[Patient] is homebound due to [functional limitation(s)/clinical condition(s)] and requires [assistive device / human assistance (number of persons) / transportation assistance] to leave home; departures require [considerable and taxing effort / are medically contraindicated]. Acceptable absences: [medical care / religious services / brief, infrequent essential activities].

Qualifying Limitations: [SOB / Pain / Weakness / Poor balance / Cognitive impairment / Safety risk / Other: ____] (Select all that apply)

Required Assistance: [Verbal cueing / Physical assist / AD: cane-walker-wheelchair / Environmental mods / Other: ____]

Functional & Cognitive Status

• ADLs: [Bathing], [Dressing], [Toileting], [Grooming], [Feeding], [Med management] – [Independent / Supervision / Min A / Mod A / Max A / Dep] (Specify for each)
• Mobility/Transfers: [Bed mobility], [Sit↔Stand], [Chair/Bed], [Toilet] – [Independent / Supervision / Min A / Mod A / Max A / Dep]; Device: [None / Cane / Walker / Wheelchair / Other]
• Gait/Balance: Distance [___ ft], Pattern [WNL / Deviations], Device [None / Cane / Walker / Wheelchair]; Fall risk [Low / Moderate / High]; Falls in last 12 mo [0 / 1+], Last fall [Date]
• Cognition: Orientation [Person / Place / Time / Situation]; Memory [Intact / Impaired]; Attention/Exec fxn [Intact / Impaired]; Decision-making [Independent / Needs cues / Dependent]; Delirium screen [Positive / Negative / Not assessed]
• Communication: Hearing [No diff / Mild / Mod / Severe], Speech [No diff / Mild / Mod / Severe], Vision [No diff / Mild / Mod / Severe]; Preferred language [____]; Interpreter needed [Yes / No]
• Behavioral/Neuropsychiatric: [No concerns / Anxiety / Depression / Agitation / Wandering / Hallucinations / Other] (Briefly note severity/impact)

Clinical Systems Review

• Cardiopulmonary: Dyspnea [Yes / No], Edema [Yes / No], Auscultation [____], Vitals [BP ___/___, HR ___, RR ___, Temp ___, SpO2 ___% on RA/O2 ___ L], Chest pain [Yes / No]
• Neurological: Focal deficits [Yes / No], Sensation [Intact / Impaired], Strength [___/5], Gait abnormalities [Yes / No], Seizure/syncope [Yes / No]
• GI/GU: Appetite [____], Bowel pattern [____], N/V [Yes / No], Incontinence [Yes / No], Devices [Catheter/Ostomy: type & status]
• Skin/Wounds: [Intact / Issues], Pressure injury [Stage ___ / N/A], Wounds [Location(s), size, drainage, periwound], Dressing [____], Infection signs [Yes / No]
• Pain: Location [____], Intensity [0–10 ___], Quality [____], Timing [____], Aggravating/relieving [____], Management effectiveness [____]
• Nutrition/Hydration: Weight [___], BMI [___], Recent wt change [Yes / No], Diet [____], Swallowing issues [Yes / No], Malnutrition risk [Low / Mod / High]
• Medications: Reconciliation completed [Yes / No], High-risk meds [Anticoagulants / Insulin / Opioids / Other: ____], Adherence issues [Yes / No], Education provided [Yes / No]

Living Environment & Supports

• Home Safety Risks: [Clutter / Poor lighting / Loose rugs / Pets / Stairs / No railings / Fire hazards / Other] (Select all that apply)
• Equipment/DME: [Walker / Cane / Wheelchair / Hospital bed / Oxygen / Grab bars / Shower chair / Other] (Note availability/condition)
• Caregiver Support: [Primary caregiver name/relationship], Availability [___ hrs/day], Ability [Trained / Needs training / Unable], Caregiver strain [Yes / No]
• Psychosocial: Mood [____], Coping [____], Social isolation [Yes / No], Financial/food insecurity [Yes / No], Advance directives on file [Yes / No]

Skilled Needs & Plan of Care

• Skilled Services Required: [SN / PT / OT / SLP / MSW / HHA] (Select all; specify focus for each)
• Visit Frequency/Duration: [Discipline: ___ x/wk x ___ wks] (One line per discipline)
• Goals: [Short-term goals] ; [Long-term goals] (Write measurable, time-bound goals)
• Interventions: [Skilled assessments/treatments/procedures planned]
• Patient/Caregiver Education: Topics [____]; Teach-back verified [Yes / No]; Written materials provided [Yes / No]
• Coordination/Orders: [Provider(s) contacted], [Orders obtained], [Referrals], [Community resources]

OASIS Item Linkage Notes

(Briefly justify scoring decisions on key OASIS items.)

• Function (ADLs/Mobility): [Narrative linkage]
• Wounds/Skin: [Narrative linkage]
• Symptoms (Dyspnea/Pain/Other): [Narrative linkage]
• Cognition/Behavior: [Narrative linkage]

Risk Alerts & Required Notifications

• Change in Condition Requiring Notification: [Yes / No] – [What changed], [When], [Whom notified], [Date/Time], [Method: Phone / Fax / EMR], [Response/Orders]
• Safety Concerns & Emergency Plan: [Fall risk / Bleeding risk / Infection risk / Suicidality / Violence risk / Other]; Emergency contacts [____]; After-hours plan [____]; 911 instructions reviewed [Yes / No]
• Vaccination/Screening Alerts: [Due items]; Education provided [Yes / No]; Declined [Yes / No]

Clinician Attestation & Completion Check

• [I verify the accuracy and internal consistency of OASIS responses, diagnoses, and plan of care.]
• [Medication reconciliation completed and variances addressed: Yes / No / N/A]
• [Homebound criteria documented and supported in chart: Yes / No]
• [Plan of care communicated to physician and orders obtained as required: Yes / No]
• [Patient/caregiver consents acknowledged: Yes / No]
• Clinician Signature/Date: [Name, credentials, signature, date]

(Keep entries concise and structured to fit one page. Use only data explicitly assessed or reported. Remove unused prompts.)