OASIS Recertification/60-Day Reassessment

Patient Name: [Patient full name]

Date of Birth: [DOB (MM/DD/YYYY)]

Visit Date/Time: [Visit date and time]

Assessment Completion Date: [Date assessment finalized (MM/DD/YYYY)]

Certification Period Closing: [Start date (MM/DD/YYYY)] to [End date (MM/DD/YYYY)]; Day [Reassessment day number] of 60

Next Certification Period: [Proposed start date (MM/DD/YYYY)] to [Proposed end date (MM/DD/YYYY)]

Assessing Clinician: [Clinician name], [Credentials], [Discipline]

(Omit sections that do not apply rather than using placeholders. For unavailable information, document the reason it could not be obtained. OASIS item-level data entry follows agency workflows and is not duplicated in narrative sections.)

Interval History / Changes Since Last Assessment

[Brief patient or caregiver statement clarifying current concerns] (Include only if it clarifies current concerns; attribute source.)

• Intercurrent care episodes: [Hospitalizations / ED visits / urgent care visits with date, facility, reason, and disposition] (Source: [patient report / caregiver report / records])
• Falls or near-falls: [Date(s), circumstances, injuries, evaluation, contributing factors]
• Infections or exacerbations: [Type, onset, treatment received, current status]
• New diagnoses or procedures: [Diagnosis/procedure and date; implications for current plan]
• Medication changes: [Additions / discontinuations / dose adjustments]; [Adherence barriers identified]
• Caregiver or support changes: [Changes in availability, capacity, or community resources]
• Service utilization changes: [Missed visits / refusals / DME changes / services added or discontinued with dates and reasons]

(If no interval events occurred: "No interval hospitalizations, ED visits, or falls reported since [prior assessment date].")

Homebound Status

(Document using Medicare's two-criterion framework with patient-specific, observable facts. Avoid stock phrases without supporting detail. Label data sources.)

Criterion 1 – Requires assistance or medical restriction to leave home: [Assistive device(s) required / hands-on assist required / medical contraindication (specify device, level of assist, or restriction and why required)] (Source: [observed / patient report / caregiver report])

Criterion 2 – Leaving home requires considerable and taxing effort: [Specific functional limitations: distance tolerance, dyspnea threshold, rest break requirements, stairs/barriers, pain with mobility, cognitive safety concerns] (Source: [observed / patient report / caregiver report])

Absences from home: [Frequency and purpose of absences (e.g., medical appointments approximately once weekly)]

Skilled Need / Continued Eligibility

(Identify why skilled services remain medically necessary using "because" statements linking clinical findings to risk and required skilled intervention. Include visit frequency rationale. Include only applicable disciplines.)

• Skilled Nursing: [Skilled nursing needed to...] because [clinical finding/risk] → [specific skilled interventions]; [Proposed frequency × duration with rationale]
• Physical Therapy: [PT needed to...] because [impairment/fall risk/functional limitation] → [specific interventions]; [Proposed frequency × duration with rationale]
• Occupational Therapy: [OT needed to...] because [ADL/IADL deficits/safety risk] → [specific interventions]; [Proposed frequency × duration with rationale]
• Speech-Language Pathology: [SLP needed to...] because [communication/swallowing/cognition issues] → [specific interventions]; [Proposed frequency × duration with rationale]
• Medical Social Work: [MSW needed to...] because [psychosocial needs/SDOH barriers] → [specific interventions]; [Proposed frequency × duration with rationale]
• Home Health Aide: [HHA services needed for...] because [ADL assistance needs beyond caregiver capacity] → [specific services]; [Proposed frequency × duration with rationale]

Reassessment Findings

(Focused clinical and functional summary supporting OASIS coding and the updated plan. Include pertinent positives and meaningful negatives only.)

• Vitals/General: BP [value]; HR [value]; RR [value]; Temp [value]; SpO2 [value]; Pain [0–10]; Weight [value if relevant]; [General appearance, orientation, communication ability, distress indicators]
• Systems Review: [Problem-focused findings by relevant systems only (e.g., cardiopulmonary, neuro, musculoskeletal)]
• Functional Status: [Ambulation method and distance; transfer status; stair negotiation; endurance; fall risk indicators; assistive devices; supervision level; ADLs/IADLs (bathing, dressing, toileting, medication management); trajectory vs prior assessment]
• Cognitive/Psychosocial: [Cognitive status affecting care; safety awareness; mood symptoms impacting function; caregiver stress/capacity]
• Pain: [Location(s); severity pattern; functional impact; current management effectiveness]
• Wounds/Integumentary: [Wound type; location; measurements (L×W×D); drainage; periwound condition; treatment response over certification period; current dressing/treatment] (Include only if applicable.)
• Medication Reconciliation: [Verification method; discrepancies and resolution status; medication-related risks; patient/caregiver understanding]
• Caregiver/Environment: [Caregiver availability and capacity; environmental hazards; safety equipment; mitigations in place or recommended]

Progress Toward Goals

(For each active problem from the current plan of care, document prior goal, status, objective evidence, barriers, and clinical significance. Organize by clinical priority.)

[Problem 1]

• Prior goal: [Goal statement from prior certification period]
• Current status: [achieved / partially achieved / not achieved]
• Objective evidence: [Measurable indicators (distances, assist level, wound measurements, adherence rates, teach-back success)]
• Barriers: [Barriers to goal achievement]
• Clinical significance if unresolved: [Risk or impact]

[Problem 2]

• Prior goal: [Goal statement]
• Current status: [achieved / partially achieved / not achieved]
• Objective evidence: [Measurable indicators]
• Barriers: [Barriers]
• Clinical significance if unresolved: [Risk or impact]

(Add additional problems as needed.)

Assessment / Clinical Impression

Overall trajectory: [improved / stable / declining]

• Active diagnoses and significant symptoms: [List in priority order with brief status]
• Risk stratification: [Fall risk level and rationale; rehospitalization risk and drivers; wound complication risk; medication safety risks] (Include applicable risks.)
• Homebound and skilled need linkage: [Explicit statement connecting current homebound status and need for skilled services to the reassessment findings above]

Plan for Next Certification Period

(Organize by problem mirroring the Assessment.)

[Problem 1]

• Interventions: [Discipline(s)] to [specific skilled interventions]; [Visit frequency × duration] (Rationale: [instability/complexity/risk driving frequency])
• Goals (60 days): [Measurable goals with clear targets and timeframes]
• Education plan: [Topics to initiate/reinforce; learner(s); barriers and strategies]
• Care coordination: [PCP/specialist communication; follow-up appointments; labs/diagnostics; DME needs]
• Discharge planning: [Anticipated criteria for discharge; contingency if goals not met]

[Problem 2]

• Interventions: [Discipline(s)] to [specific skilled interventions]; [Visit frequency × duration] (Rationale: [reason])
• Goals (60 days): [Measurable goals]
• Education plan: [Topics and needs]
• Care coordination: [Actions planned]
• Discharge planning: [Criteria and contingency]

(Add additional problems as needed.)

Provider Communication / Orders

(Include only when applicable.)

• Provider contacted: [Name, role]; [Date/time]; [Method: phone / secure message / fax]
• Reason and outcome: [Reason for contact; summary of discussion and plan]
• Orders received: [Verbal/telephone orders with specifics; read-back confirmation documented]

Education Provided

(Include only when applicable.)

• Topic(s) and method: [Topics covered]; [verbal / written / demonstration]
• Learner: [patient / caregiver / both]
• Teach-back or return demonstration: [Results and accuracy]
• Remaining gaps/barriers: [Description and plan to address]

Signature

Clinician Signature: [Signature], [Credentials], [Date/Time]

This assessment reflects a unique reassessment performed today within the days 56–60 certification period closing window. Plan recommendations align with the reassessment findings documented above. OASIS responses, if completed, are supported by the documented findings. This reassessment supports physician recertification for the next certification period.