Understanding OASIS More Deeply

For more than 15 years, home health nursing wasn’t simply my profession—it was my calling.

Being invited into a patient’s home is a privilege I never took lightly. Home health taught me not only how to care for patients, but how important it is to earn their trust, listen to their story and understand what is really happening in the home.

I never imagined there would come a time when I could no longer do the work I loved, but a devastating automobile accident left me with injuries that made returning to field nursing impossible. I thought I had lost not only my career, but my calling.

With the encouragement of my husband, I eventually realized that although I could no longer walk through patients’ front doors, I hadn’t lost the knowledge, compassion or passion that home health had given me. There was another way for me to continue serving the profession I loved.

That journey eventually became Kupono Solutions.

Today, I have the privilege of working alongside an incredible team of nurses who share my passion for supporting home health agencies and the clinicians who care for their patients. Through that work, one lesson continues to stand out: Clinicians are often not struggling because they lack clinical knowledge or compassion. Sometimes they simply have never been taught what an Outcome and Assessment Information Set (OASIS) item is really asking.
Understanding that “why” can change the way a clinician approaches the entire assessment.

Teach the Intent, Not Just the Answer

Every OASIS item has a purpose. The goal should not be to teach clinicians which box to check. It should be to help them understand the intent of the item, assess the patient completely and select the response supported by that assessment.

Here are a few examples I encounter in clinical review:

➡ M1033: Small details can make a difference. 
M1033, risk for hospitalization, is a great example of why understanding the “why” behind the OASIS process. It’s easy to look at it as a list of boxes to check, but every one of those questions is helping us tell a bigger story about that patient and their risk for hospitalization. Sometimes it’s the small details we overlook that can make a difference.
Clinicians may remember the “two or more falls” portion of M1033 and overlook the second part: any fall with an injury within the past 12 months. A patient does not have to experience multiple falls for this risk factor to apply—one fall with an injury is enough.

That small distinction can easily be missed, which is why understanding the full OASIS question matters. Instead of only asking, “Has the patient fallen more than once?” clinicians should also ask whether the patient experienced an injury with any fall during the past 12 months.

Once clinicians understand why that distinction matters, they can carry that knowledge into future assessments.
Just like with falls, understanding what M1033 is looking for helps us know what questions to ask. Those small details allow us to more accurately capture the patient’s history and their risk for hospitalization.

➡ M1840: Assess what is available today. 

M1840, toilet transferring, is another example of why understanding the full question matters.

A clinician may recognize that a patient who cannot safely get to the toilet could use a bedside commode and select a response based on that ability. But what if the bedside commode isn’t actually in the home at the time of the assessment?

This is where we have to slow down and look at what is happening in the home. Instead of only asking, “Could this patient use a bedside commode?” we also need to ask, “Is the equipment available today, and what can this patient safely do with what is currently in the home?”

It can be easy to think ahead to what the patient will be able to do once the equipment arrives, but the OASIS response needs to reflect the patient’s current ability at the time of assessment, not what we anticipate their ability will be after the equipment is in place.

Once clinicians understand that distinction, they begin looking beyond the response itself and thinking about what they are actually seeing in the home.

➡ M2020: Look at the entire medication task.

M2020, management of oral medications, is another question where clinicians may understand part of the task but overlook something that can change the response.

Clinicians often focus on whether the patient knows which medications to take and when to take them. But knowing the medication regimen does not necessarily mean the patient can safely and reliably manage it.

This is where I encourage clinicians to look beyond the medications sitting in front of them and think about the entire task. Where are the medications routinely stored? Can the patient safely get to them? Can they open the containers, prepare the correct dose and take the medications at the appropriate time? And something that can easily be overlooked: Can the patient safely get a drink to take those medications?

For example, a patient may know every medication they take and exactly when they are supposed to take it. But if those medications are routinely stored in the kitchen and the patient cannot safely get to the kitchen without another person’s assistance, that matters. The same is true if the patient requires assistance to access the beverage needed to safely take the medication.

Instead of just asking, “Do you know which medications you take?” we need to ask questions such as, “Where do you keep your medications?” “Can you safely get to them?” and “Can you safely get what you need to take them?”

A patient can know their medication regimen perfectly and still not be independent in managing it. Understanding the intent behind M2020 helps us assess what the patient can actually do safely and reliably, not simply what they know.

Turn Corrections Into Education

This philosophy is at the heart of how we approach coding and clinical review at our organization. The goal isn’t simply to identify a response that needs to be reconsidered, change an answer and move on to the next chart. We want the review itself to become an opportunity for education.

When we question a response, we want the clinician to understand why. What is the item actually asking? What did you observe? What documentation supports your response? Is there another question you could have asked to get a more complete picture of the patient?

Correcting one response may improve one assessment. Helping a clinician understand the reasoning behind it can influence every assessment that clinician completes afterward.

Through coding and review, we work to help clinicians better understand the intent behind OASIS, apply their clinical judgment and document the patient story that supports their response.

Documentation Should Tell the Same Story

That same principle extends beyond OASIS. The diagnoses, assessment findings, interventions, goals, physician orders and visit documentation should support one another and tell a consistent story about the patient and the care being provided.

Home health clinicians have already done the hard work. Our privilege is helping ensure the documentation reflects it.
Behind every chart is a patient. Behind every assessment is a clinician. The documentation should reflect the excellence of both.

Although I no longer carry my nursing bag from home to home, I still have the privilege of caring for patients. Today, I simply do it differently. One chart at a time.