OASIS Start of Care Comprehensive Assessment (SOC)

Note Type: OASIS SOC Comprehensive Assessment

Patient: [name and identifiers per policy]

Date/Time of Visit: [date; time in / time out]

SOC Date: [if different from visit date]

Location: [private home / ALF / group home / other]

Clinician: [name, credentials, discipline]

Ordering/Referring Practitioner: [name, contact]

Primary Care Practitioner: [name, contact]

Payer(s): [payer name(s)]

Present: [patient; caregiver(s) with relationship; interpreter if used]

Reason for Visit & Clinical Summary

[Chief concern in patient's words and reason for home health referral] (Include recent care transitions if applicable: facility, dates, primary diagnosis, key discharge instructions. Describe current symptoms and trajectory since discharge or precipitating change. If no recent hospitalization, document community baseline and what prompted referral.)

[Prior functional level compared to current baseline; patient goals and preferences] (Note supports available and living situation. Use direct quotes for goals when meaningful. Limit to 1–2 concise paragraphs.)

Eligibility Support

Homebound Status

• Mobility limitations: [devices used; assistance level required to exit home; environmental barriers such as steps, distance, terrain] (Source: [Observed / Patient reported / Caregiver reported])
• Taxing effort: [symptoms with exertion: dyspnea, fatigue, pain, unsteadiness; onset and duration] (Source: [Observed / Patient reported / Caregiver reported])
• Absences from home: [frequency, purpose, duration of outings] (If patient leaves home regularly, explicitly address whether homebound criteria are met.)
• Summary: [Clear, audit-ready statement linking observations to Medicare homebound criteria] (Avoid boilerplate; use patient-specific clinical reasoning.)

Skilled Need Rationale

(For each ordered discipline, document what skilled service is required, why it is needed, and why patient/caregiver cannot safely perform without skilled involvement.)

• Skilled Nursing: [skilled service(s)] — [clinical complexity/instability/safety rationale] — [why patient/caregiver cannot perform]
• Physical Therapy: [skilled service(s)] — [clinical complexity/instability/safety rationale] — [why patient/caregiver cannot perform]
• Occupational Therapy: [skilled service(s)] — [clinical complexity/instability/safety rationale] — [why patient/caregiver cannot perform]
• Speech-Language Pathology: [skilled service(s)] — [clinical complexity/instability/safety rationale] — [why patient/caregiver cannot perform]

(Include only ordered disciplines; delete others.)

Comprehensive Assessment

(For each domain, indicate source: Observed / Patient reported / Caregiver reported / Records reviewed. Omit systems not relevant to current conditions unless policy requires; if omitted, note "Not assessed—[reason]; will assess [when].")

Vitals & General

• Vitals: BP [__] mmHg; HR [__] bpm; RR [__]; Temp [__]; SpO2 [__]% on [room air / O2 at __ L/min]
• Weight: [__] (note significance for CHF/fluid status if applicable)
• Pain: [location; intensity on 0-10 scale; pattern; functional impact; current interventions]
• General: [appearance; hydration; edema location and severity]

Cardiopulmonary

• [Breath sounds; work of breathing; cough and sputum characteristics]
• [Heart sounds/rhythm if assessed; peripheral edema; capillary refill]
• [Red flags reviewed with patient/caregiver; understanding demonstrated: yes/no]

Neurological/Cognitive

• [Orientation; baseline cognition; alertness]
• [Standardized screening if completed: tool name, score, clinical interpretation, impact on self-management]
• [Safety awareness; judgment; executive function concerns]

Mood/Psychosocial

• [Depression screening: tool, score, interpretation; follow-up actions if positive]
• [Anxiety; isolation; coping; caregiver stress/burden]
• [Abuse/neglect concerns and actions taken] (Include only if concerns identified.)

GI/GU

• [Appetite; diet tolerance; bowel pattern; constipation risk and interventions]
• [Urinary symptoms; continence status; incontinence management if applicable]
• [Catheter: type, size, insertion date; site condition; drainage; care plan] (Include only if applicable.)

Skin/Wounds

• Skin integrity: [overall condition; pressure injury risk indicators]
• Wound (repeat for each):
  • Location: [__]; Etiology: [__]
  • Measurements: [L x W x D cm]; Undermining/tunneling: [clock positions or none]
  • Wound bed: [__]; Drainage: [amount / type / odor]
  • Periwound: [__]; Infection signs: [present / absent]
  • Current treatment: [orders vs. what patient is doing]; Supplies: [on hand / needed]

Musculoskeletal/Mobility

• [Strength and ROM by key joints; pain with movement]
• [Balance; gait quality; assistive device; transfers; stairs]
• [DME: type, fit, condition, safe use]

Sensory/Communication

• [Vision deficits and corrective aids; hearing deficits and aids]
• [Speech clarity; aphasia type if present; communication methods; swallowing concerns]

Nutrition

• [Diet type and restrictions; hydration status; nutritional risk factors]
• [Diabetes management if applicable: glucose monitoring frequency, recent values, targets, foot inspection findings]

Functional Status & Safety

ADLs

(Use consistent terminology: Independent / Supervision / SBA / Min Assist / Mod Assist / Max Assist / Dependent. Note devices used.)

• Bathing: [assist level; device; safety concerns]
• Dressing: [upper body / lower body assist levels]
• Toileting: [assist level; equipment]
• Grooming: [assist level]
• Transfers: [bed / chair / toilet; assist level; device]
• Ambulation: [distance; device; assist level; gait deviations]
• Stairs: [number of steps; rails; assist level]
• Eating: [assist level; special needs]
• Objective mobility test: [test name, result, interpretation] (Include if performed.)

IADLs & Self-Management

• Medication management: [ability to manage; barriers: cognition, vision, dexterity, literacy, cost]
• Household tasks: [meal prep; housekeeping; shopping; laundry—who performs]
• Communication/transportation: [phone use; transportation access; ability to follow written instructions]
• Caregiver support: [availability; role; limitations]

Home Environment

• Access: [entry steps; interior stairs; rails present]
• Bathroom: [safety equipment present / needed: grab bars, shower chair, raised toilet seat]
• Hazards: [clutter; lighting; rugs/cords; oxygen safety if applicable]
• Emergency preparedness: [phone access; how patient summons help; posted emergency contacts]

Risk Summary

• Falls: [risk level; tool and score if used; contributing factors; mitigation plan]
• Pressure injury: [risk factors; prevention interventions]
• Medication: [polypharmacy; high-risk meds; adherence concerns; mitigation plan]
• Rehospitalization: [risk factors; red flag education provided; escalation plan]

Medication Reconciliation & Safety

Reconciled Medication List

(List all prescription meds, OTCs, herbals/supplements, PRNs. Verify against bottles in home, discharge list, and/or referral.)

• Allergies: [substance — reaction type/severity] (If NKDA, state "No known drug allergies.")
• [Medication name] — [dose] — [route] — [frequency] — [indication] — Source: [bottles / discharge list / referral]
• (Repeat for each medication.)
• (If no medications: "No medications taken per [verification method].")

Discrepancies & Adherence

• Discrepancies identified: [missing med / duplicate / wrong dose / expired / other] — [sources compared] — [clinical relevance] — [action taken]
• Adherence barriers: [cognition / vision / dexterity / cost / complexity] — [strategies implemented]
• High-risk medications: [anticoagulants / insulin / opioids / other] — [safety teaching provided] — [patient/caregiver verbalized understanding: yes/no]

Medication Issues & Actions

(Document clinically significant issues requiring practitioner contact per OASIS requirements.)

• Issue: [specific medication issue]
  • Practitioner contacted: [name] via [phone / portal / fax] on [date/time]
  • Outcome: [orders received / instructions / pending callback]
  • Actions: [completed / pending—who will do what by when]
  • OASIS completion status: [Completed / Pending / Not completed—reason and follow-up plan]

(Repeat for additional issues. If no issues identified, state "No clinically significant medication issues identified.")

Assessment & Plan

(Organize by problem in descending order of severity/risk.)

Problem 1: [Diagnosis/condition]

• Baseline: [current status with objective data from this visit]
• Skilled rationale: [why skilled service is needed for this problem]
• Interventions today: [assessment and treatments performed during SOC]
• Education: [topics taught; method; patient/caregiver response; teach-back results]
• Goal(s): Patient will [action] with [assist level/device] for [metric] within [timeframe].
• Plan: [disciplines involved; visit focus; monitoring parameters; escalation criteria]

Problem 2: [Diagnosis/condition]

• Baseline: [current status]
• Skilled rationale: [reason for skilled need]
• Interventions today: [completed]
• Education: [topics; response]
• Goal(s): Patient will [action] with [assist/device] for [metric] within [timeframe].
• Plan: [next steps; monitoring; escalation]

(Add additional problems as applicable.)

Care Coordination & Orders

• [Date/time] — [Orders received/confirmed; include verbal order read-back]
• [Date/time] — [DME / supply / lab / referral requests and status]
• [Date/time] — [Practitioner communication: name, method, reason, outcome]
• [Date/time] — [Coordination with caregiver or facility staff]
• (If unable to reach provider: [attempts documented; fallback plan])
• (If no communications required: "No practitioner contact required today.")

Service Plan Summary

• Disciplines: [SN / PT / OT / SLP / MSW / HHA]
• Visit frequency/duration: [proposed schedule by discipline]
• Next visit focus: [primary objectives for next visit]
• Escalation criteria: [when to contact practitioner / move up visit / call 911]

Authentication

Clinician Signature: [e-signature]

Credentials: [__]

Date/Time Signed: [__]

Attachments reviewed: [discharge summary / medication list / referral / wound photos / other]

Documentation Conventions

• Missing information: Never leave required fields blank. Use: "Unknown—unable to obtain today [reason]; plan to obtain from [source] by [date]" or "Patient declined to answer" or "Not assessed due to [reason]; will assess at next visit." For eligibility, medications, and safety domains, always include a follow-up plan.
• Source attribution: Label key findings as Observed / Patient reported / Caregiver reported (relationship) / Records reviewed (source name).