The updated OASIS C-2 Guidance Manual took effect last January 1, 2018 and MyHomeCareBiz is fully prepared to provide you with guidance on the most recent updates. One significant matter to note is that the OASIS data sets remain the same and have not changed any item. This version replaces the previous guidance manual in its entirety. It corrects some minor typos from the January 1, 2017 version and contains clarifications about the One Clinician Rule.
So, what is ‘One Clinician Rule’? As it was with the previous version, only one clinician is responsible to complete the OASIS; however, effective January 1, 2018, collaboration with other members of the team involved in patient care is allowed. It includes collaboration with the patient, caregivers and other agency health care staff, including but not limited to physician, pharmacists and/or other staff to help in the completion of the assessment.
According to CMS, some parts of the clinical records may be put in initially by a clerical staff as part of the referral or intake process, but these should be verified by the assigned clinician during the assessment visit.
Data collection should be done by a registered nurse (RN) or any of the therapists, including physical therapist (PT), speech language pathologist/speech therapist (SLP/ST), or occupational therapist (OT). The assessing clinician should take responsibility in considering valid inputs and ensuring that these data are from collaborating members of the health team who have had direct patient contact.
Since collaboration is allowed, M0090 (Date Assessment Completed) should be the LAST DAY the clinician received and accepted any input used to complete the OASIS.
Moreover, it is the responsibility of the agency to establish protocols in relation to team collaboration, paying particular attention to documentation of assessment information coming from different sources using the agency’s communication tools within accepted standards of practice. Depending on the agency’s preference, they may continue to limit the completion of the OASIS to only one assessing clinician.
It is likewise significant to mention that for every episode or time point, a new patient assessment should be performed to document the patient’s actual condition at the time of the assessment and not just answers copied from the previous episode. The plan of care should of course be consistent with the gathered data, so the orders and diagnoses should be up-to-date.
It is highly recommended that the manual is printed and accessible to all agency staff and clinicians for ready reference. Chapter 1 of the guidance manual contains clarifications about One Clinician Rule (download link is included on this blog).