OASIS Discharge Assessment/Discharge Summary (Home Health)

Document Header

Patient: [Full legal name], DOB: [DOB], MRN/Agency Patient ID: [Identifier]

Agency: [Agency name], [Branch/CCN if applicable]

Episode: Start of Care: [SOC date] | Certification Period: [From date – To date] | Primary Payer: [Payer name]

Ordering Practitioner: [Name], [Credentials], [Contact information]

Author: [Discipline/role], [Credentials], Completion Date/Time: [Date/time], Signature: [Electronic signature/attestation]

DISCHARGE SUMMARY

Discharge Event

Discharge Type: [Discharge from agency (not to inpatient) / Transfer to inpatient facility (planned/unplanned; expected to resume home health: Yes/No/Unknown) / Transfer to another HHA / Transition to home hospice / Transition to institutional setting (SNF/IRF/LTCH/NF) / Death at home]

Discharge Date: [Event date] | Last in-person visit: [Date if different]

Reason for Discharge: [Goals met/outcomes achieved / No further skilled need / No longer homebound / Patient refusal/elected discharge / Transfer/hospitalization / Payer/coverage ended / Agency unable to meet needs/higher level of care required / Discharge for cause / Moved out of area/unable to contact / Death]

[Narrative justification with objective anchors] (1–3 sentences citing objective evidence; avoid conclusory phrases without supporting documentation.)

Episode Synopsis

(Omit this section entirely for non-admit/no-start cases.)

[Why admitted to home health: referring diagnoses and precipitating event; disciplines/services provided; major changes or turning points during episode] (Summarize in 2–4 sentences.)

Significant Events During Episode: (Include only if applicable.)

• [Date] – [Event: ER visit/hospitalization/fall/adverse drug event/infection/wound complication/new diagnosis/caregiver or living situation change] – [Source and limitations if details incomplete]

Final Status at Discharge

(Document specific, observable, actionable information for the next clinician.)

Clinical Status:

• [Vital signs at/near discharge with dates]
• [Weight and trend if clinically relevant]
• [Symptom stability: dyspnea, pain, edema, glucose control, etc.]
• [Disease-specific endpoints]
• [Wounds: location, measurements, stage/type, drainage, periwound, last dressing type/date, current status] (Include only if applicable.)
• [Lines/tubes/drains: type, site condition, last care date, disposition] (Include only if applicable.)
• [Infections: signs/symptoms, antibiotic course status, remaining concerns] (Include only if applicable.)
• [Safety risks at discharge and mitigations in place: falls, medication safety, aspiration, pressure injury]

Functional Status:

• [Mobility: bed mobility, transfers, ambulation distance/device/terrain, stairs – assistance level for each]
• [ADLs: bathing, dressing, grooming, toileting, feeding – assistance level and who provides it]
• [IADLs: meal prep, medications, finances, transportation – current supports/limitations]
• [Home environment constraints and equipment in place]

[1–2 sentence interpretation of functional readiness for discharge] (Ground in observed performance or validated tools.)

Cognitive/Psychosocial: (Include only when relevant to discharge safety.)

• [Cognitive/behavioral factors impacting safety or self-management]
• [Mood/adherence concerns and impact on plan]
• [Social determinants directly affecting discharge safety and follow-up]

Goal Outcomes

(Omit if no plan of care existed. Order by clinical risk, highest first.)

• [Discipline/Goal area]: [Goal statement]
  Baseline → Discharge: [Baseline status] → [Discharge status]
  Outcome: [Met / Partially met / Not met / Not addressed] – [Reason if not met or not addressed]
  Evidence: [Brief objective evidence supporting outcome]

(If any goals not met: identify remaining deficits, justify why discharge is appropriate, and document safety plan.)

Medication Disposition

Allergies: [Allergen(s)] – [Reaction(s) and severity]

Current Medications: (Include Rx, OTC, supplements/herbals. Flag high-risk medications with monitoring needs.)

Name	Strength	Dose	Route	Frequency	Indication	Special Instructions/Monitoring
[Medication name]	[Strength]	[Dose]	[Route]	[Frequency]	[Indication]	[Monitoring needs, precautions]

Adherence Risks & Mitigations: [Pillbox, caregiver setup, pharmacy delivery, language support, etc.]

Changes During Episode:

• New: [Medication] – [Date] – [Reason/source]
• Stopped: [Medication] – [Date] – [Reason/source]
• Dose change: [Medication] – [Date] – [New regimen] – [Reason/source]

(If list finality uncertain, state last verified source/date and reason.)

Medication List Provision: Reconciled list provided to patient/caregiver: [Yes / No] | Transmitted to subsequent provider: [Yes / No / N/A] | Method: [EHR/portal / HIE / Paper/fax / Verbal]

Patient/Caregiver Education

• [Medication education: purpose, dosing, side effects, missed dose instructions]
• [Wound/line/tube care and supplies management] (If applicable.)
• [Disease self-management and red flags; when to call provider vs emergency services]
• [Safety education: fall prevention, pressure injury prevention, aspiration precautions]
• [Equipment use and maintenance] (If applicable.)
• [Caregiver-specific training] (If applicable.)

Teach-back/Demonstration: Performed: [Yes / No] | Competence demonstrated by: [Patient / Caregiver / Both] | Method: [Describe teach-back or return demonstration] | Residual gaps: [Describe or "None"] | Mitigation plan: [Describe if gaps present]

Patient/Caregiver Quote: "[Brief direct quote summarizing key instructions]" (Include when available.)

Follow-up Plan

Post-Discharge Responsibility: [Clinician/practice name], [Contact info] (If unknown, document attempts made and instructions given to patient.)

Scheduled Follow-ups:

• [Date/time] – [Provider/Location] – [Purpose] – [Transportation plan if barriers exist]
• [Ordered labs/INR checks/infusions/wound clinic visits with details]

Referrals and Ongoing Services:

• [Outpatient therapy: PT/OT/SLP – referral status]
• [Community nursing / hospice / palliative care – referral status]
• [DME vendor/equipment status]
• [Community resources: meals, caregiver support, transportation]
• [Transfer to another HHA: handoff status and anticipated start date] (If applicable.)

Communication Log

• Ordering practitioner notified of discharge/transfer: [Name], [Date/time], [Method]
• Discharge summary sent: [Recipient], [Date/time], [Method] (Required within 5 business days.)
• Transfer summary sent: [Recipient facility/unit], [Date/time], [Method] (Required within 2 business days; include only if transfer.)
• Unable to reach recipient: [Attempts documented and alternate routing used] (If applicable.)

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OASIS DISCHARGE ASSESSMENT

(Complete using the OASIS item set in effect for M0090 date. This must reflect a unique assessment for this time point—do not copy forward from prior assessments. When data unavailable, use permitted "unknown/not applicable" responses and document why. Clearly document data sources for items not directly assessed.)

Assessment Completion Date (M0090): [Date]

Data Sources Used: [In-person assessment / Caregiver report / Record review / Clinician-to-clinician call / Medication containers / Discharge paperwork]

Administrative Items

• Assessment Timepoint: [Discharge from agency / Transfer to inpatient facility (planned/unplanned)]
• Reason patient not available for direct assessment: [Reason and alternative sources used] (If applicable.)
• Residential status: [Private home/apartment / Board-and-care / Assisted living / Other]

Utilization Since SOC/ROC

• Emergency department visits: [0 / 1 / 2 / 3+] – [Dates and reasons if any; source]
• Inpatient facility stays: [None / Acute hospital / IRF / SNF / LTCH / Psychiatric] – [Dates, planned vs unplanned; source]

Discharge Disposition

[Community without formal services / Community with formal services / Institutional setting (SNF/IRF/LTCH/NF) / Home hospice / Deceased / Other]

Functional Items at Discharge (GG Items)

(Score usual performance over assessment period. Use OASIS response options: Independent / Setup or clean-up / Supervision or touching assist / Partial/moderate assist / Substantial/max assist / Dependent / Not attempted—medical or safety reason / Not applicable.)

• Self-Care (GG0130): [Eating, oral hygiene, toileting hygiene, shower/bathe, upper/lower body dressing, footwear – score each]
• Mobility (GG0170): [Roll, sit to lying, lying to sitting, sit to stand, transfers, toilet transfer, car transfer, walking distances, stairs, picking up object – score each applicable item]
• Wheelchair (if used): [Wheel 50 ft with turns, wheel 150 ft – score each]

Integumentary Items

• Pressure injuries: [Number by stage at discharge; healed count; unstageable categories]
• Stasis ulcers: [Number; healing status]
• Surgical wounds: [Number; status]

Clinical Items

• Respiratory: [Oxygen use/device/liters/frequency; dyspnea assessment] (If applicable.)
• Cardiac: [Edema, weight monitoring, symptoms] (If applicable.)
• Pain interference: [Response per OASIS item] (If collected at discharge.)
• Cognitive/behavioral: [Orientation, attention, communication per OASIS items] (If collected at discharge.)

Falls Since SOC/ROC

• Any falls: [Yes / No / Unknown]
• Number of falls: [0 / 1 / 2–3 / 4+]
• Falls with major injury: [0 / 1 / 2+]

Special Treatments and Programs

[Dialysis / IV medications / Parenteral nutrition / Enteral feeding / Oxygen therapy / Ventilator / Chemotherapy / Radiation / Hospice / Other] – Active during assessment period: [Yes / No for each applicable]

Medication Items

• Medication list provided to patient/caregiver: [Yes / No] – [Reason if No]
• Medication list transmitted to subsequent provider: [Yes / No / N/A] | Method: [EHR/portal / HIE / Fax/paper / Verbal]
• High-risk drug classes (N0415): Anticoagulants [Y/N], Antiplatelets [Y/N], Hypoglycemics [Y/N], Opioids [Y/N], Antipsychotics [Y/N], Benzodiazepines [Y/N]

Additional Required Items

[Any additional items required by current OASIS instrument for this discharge timepoint] (Refer to current OASIS-E guidance for complete item set.)