OASIS Resumption of Care Comprehensive Assessment (ROC)

Patient name: [Patient full name]

DOB: [MM/DD/YYYY]

MRN: [Medical record number]

Address/location of visit: [Full address and setting: home / ALF / other]

Visit type: ROC Comprehensive Assessment

Clinician name and credentials: [Clinician full name, credentials]

Date and time of visit: [MM/DD/YYYY, HH:MM]

Primary physician/ordering practitioner: [Name, specialty, contact]

Payer: [Payer/plan name and member ID]

Persons present: [Patient alone / caregiver(s): name, relationship / interpreter: language, modality]

ROC Trigger and Inpatient Stay Summary

Facility: [Facility name], [hospital / SNF / IRF / LTCH]
Admission date: [MM/DD/YYYY]   Discharge date: [MM/DD/YYYY]
Primary inpatient diagnoses: [List]
Key procedures or complications: [List key procedures, notable events, complications]
New restrictions/orders: [weight-bearing / diet / activity / oxygen / driving / none]
Discharge disposition: [Home / Home with services]
Scheduled follow-up appointments: [Provider, date, purpose] (Include only if scheduled.)
Pending results: [List pending labs/imaging and plan to obtain, or "None known"]
Discharge paperwork status: [Available / Unavailable] (If unavailable, document attempts to obtain and interim sources used: patient recall, pharmacy, portal, pill bottles.)
Patient remained on home health service during inpatient stay: [yes / no] (If no, complete SOC documentation instead.)

Sources Reviewed

[List documents reviewed with dates: discharge summary, discharge medication list, prior home health medication list and plan of care, recent labs/imaging, therapy discharge instructions, wound orders, pharmacy printout, pill bottles observed, other]

Reason for Visit and Interval History

[Narrative summary of patient's primary concerns since returning home, comparing current status to pre-hospital baseline: what is better, worse, or new] (Start with patient's stated concerns. Include focused review of high-risk transition symptoms: dyspnea, chest pain, dizziness, fever, wound changes, confusion, falls, GI symptoms, poor intake, uncontrolled pain. Use direct patient quotes selectively for new/worsening symptoms, adherence barriers, or safety concerns.)

Objective Assessment

General appearance: [Well-appearing / mildly / moderately / severely ill]; [no / mild / moderate / severe] distress; [positioning, communication, devices present]

Vital signs: [BP, HR, RR, Temp, SpO2, Weight] (Include orthostatics if indicated: supine/sitting/standing values and symptoms.)

Pain: [Location, severity 0–10, quality, functional impact, current regimen, effectiveness]

Cardiopulmonary: [Work of breathing; oxygen use: none / PRN / continuous with flow rate; lung sounds; edema location and grade; JVP if assessed]

Neurological/cognitive red flags: [Orientation, new confusion or delirium indicators, attention, focal deficits, gait/balance]

Skin integrity and wounds: [Overall skin assessment; wound(s) by location with size L×W×D cm, tissue type, exudate, odor, peri-wound, tunneling/undermining, current dressing] (Include only if applicable.)

Nutrition/hydration: [Diet orders, appetite/intake, swallowing issues, hydration status, recent weight change]

(Omit stable, irrelevant systems; do not omit OASIS-required domains. If a required domain was not assessed, state reason and plan to reassess.)

Functional Status and Fall Risk

ADLs: (Mark each as observed or reported.)

• Bathing: [independent / supervision / CGA / min A / mod A / max A / dependent]
• Dressing: [independent / supervision / CGA / min A / mod A / max A / dependent]
• Toileting: [independent / supervision / CGA / min A / mod A / max A / dependent]
• Transfers: [independent / supervision / CGA / min A / mod A / max A / dependent]
• Ambulation: [distance, device, level of assist]
• Medication management: [independent / setup / partial assist / full assist]

Assistive devices: [none / cane / walker / wheelchair / hospital bed / commode / other]; Safety with use: [safe / requires cues / unsafe behaviors observed]

Falls since discharge: [number, circumstances, injuries]   Near-falls: [number]

Home environment hazards: [clutter / poor lighting / loose rugs / stairs / pets / lack of grab bars / none]

Comparison to pre-hospital baseline: [improved / similar / worsened] with specifics

Cognitive, Mood, and Capacity

Cognition: [Orientation, attention, memory, safety awareness]

Mood/behavioral screening: [Tool and score / screened negative / declined]; [notable behavioral symptoms affecting care]

Health literacy: [adequate / limited]; [teach-back accuracy]

Decision-making capacity: [intact / partial / lacks capacity]; Support: [health care proxy/POA if applicable]

Medication Reconciliation

Allergies and adverse reactions: [Allergen: reaction type]

Reconciled medication list: (Compare prior home health list, inpatient discharge list, and what patient is actually taking. Verify using bottles/blister packs when possible.)

• [Medication – strength, route, dose, frequency, indication; source: discharge list / prior HH list / bottle verified]
• [Additional medications as needed]

Discrepancies identified:

• [Discrepancy description: discharge list states X vs patient taking Y] Risk: [duplication / interaction / omission / incorrect dose / other] Action: [held / continued / changed pending confirmation]
• (Repeat for each discrepancy.)

Provider communication: [Name/role contacted, date/time, method, issue communicated, orders received, actions completed] (Per CMS, clinically significant medication issues require follow-up with physician/allowed practitioner by end of next calendar day.)

High-risk medication education: [anticoagulants / opioids / hypoglycemics / sedatives]; Teach-back: [accurate / partial / needs reinforcement]

If medications cannot be verified: [Interim list source, safety plan, follow-up timeline and responsible party]

Equipment and Supplies

(Include only if relevant.)

New/changed equipment: [oxygen / walker / hospital bed / wound supplies / other]

Safety/fit issues: [describe / none]   Patient competence: [competent / needs reinforcement / unsafe]

Supply gaps: [what is missing, who will supply, by when, interim plan]

Homebound Status

[Patient-specific narrative explaining why leaving home requires considerable and taxing effort: functional limitations, symptoms with exertion, endurance limits, assistance required, home egress barriers, safety risks. Note permitted brief absences for medical care. Avoid generic statements; describe the specific clinical picture.]

Skilled Need

[Explicit description of why skilled nursing and/or therapy is required: complexity, instability, assessments needed, medication management, wound care, caregiver training, safety education, therapy progression. Specify skilled tasks and clinical judgment required, and why non-skilled care is insufficient.]

Assessment and Diagnoses

Active problems requiring intervention:

• [Problem/diagnosis] – [brief synthesis of status and key risks]

Monitored stable conditions:

• [Condition] – [stable/controlled; monitoring plan]

Primary diagnosis driving plan of care: [Primary diagnosis]

Risk Factors and Safety Plan

Readmission/ED risk drivers: [polypharmacy / recent falls / inadequate caregiver / cognitive impairment / uncontrolled symptoms / wound infection risk / poor access to meds or food / other]

Risk mitigation interventions: [specific monitoring parameters, thresholds, early warning signs, home safety changes, adherence supports]

Escalation pathway: [who to call for what; after-hours plan; when to call 911]

Scheduled follow-ups: [home health revisit schedule, provider appointments, lab dates]

Plan of Care Update

(Organize by problem in descending clinical risk priority.)

[Problem #1]: [Post-hospital status]

• Interventions and monitoring: [skilled tasks, frequency, parameters]
• Education goals: [topics, mastery criteria]
• Coordination tasks: [orders, referrals, labs]
• Measurable goals: [goal, target, timeframe]

[Problem #2]: [Post-hospital status]

• Interventions and monitoring: [skilled tasks, frequency, parameters]
• Education goals: [topics, mastery criteria]
• Coordination tasks: [orders, referrals, labs]
• Measurable goals: [goal, target, timeframe]

Services resuming/changes from pre-hospital POC: [Resume SN/PT/OT/ST/MSW/HHA; new frequencies; holds; discontinuations]

Pending physician orders: [List pending items and interim safety steps]

Visit schedule by discipline: [Discipline: frequency x weeks, start date]

Orders and Communication

Orders obtained today: [verbal / written], [date/time], [ordering practitioner], [specific orders]

Communications sent: [recipient, date/time, method, content, response]

Caregiver notification: [who, date/time, changes communicated]

Patient and Caregiver Education

Topics taught: [medication changes / symptom monitoring / wound care / diet / oxygen safety / device use / fall prevention]

Learner: [patient / caregiver]   Method: [verbal / demonstration / printed]   Response: [accurate / partial / needs reinforcement]

Written materials provided: [visit schedule / medication schedule / treatment instructions / agency contact / escalation instructions]

Discharge Planning

Anticipated discharge criteria: [functional goals / wound healing / education complete / medication stability]

Expected timeframe: [if known]

Barriers and mitigation: [transportation, caregiver, equipment, adherence; plan to address]

Clinician signature and credentials: [Signature, credentials]   Date/time of authentication: [MM/DD/YYYY HH:MM]

(If information was not assessed or unavailable, document reason and follow-up plan rather than leaving blanks. OASIS data capture may be completed in separate structured format per agency workflow.)