by Lori Marmon, PT, MBA, COS-C
The OASIS-E instrument that became effective January 1, 2023, includes some items that direct providers to limit the data source used to select coding responses to patient self-report only.
As part of the completion of the comprehensive assessment, including OASIS, agencies gather the necessary information to complete the accurate coding of OASIS items. These assessment strategies can include methods such as direct observation, collaboration, medical record review and interview, unless otherwise noted in guidance.
Note that some OASIS-E items do have relatively restrictive item specific guidance directing how data can be gathered for selecting the responses, specifically that providers should utilize patient self-report as the only data source. Two notable examples include:
B1300 – Health Literacy and D0700 – Social Isolation
In the OASIS Guidance Manual, these two items are specifically identified as “patient self-report items.” The guidance is clear that for these items no other sources should be used to identify the response. This means that for these two items, typical data sources (like the patient’s medical record or a proxy (family, a caregiver, friend, Power of Attorney or health care representative) cannot be used as the data source to determine the OASIS responses for Health Literacy and Social Isolation.
When selecting the response codes for these two items, the strategy could be fairly straightforward.
For B1300 – Health Literacy, the patient would be asked, “How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?” Based on the patient’s response to this question, select the response frequency that best reflects how often the patient reports needing help reading the instructions provided by their doctor or pharmacy will be reported.
For D0700 – Social Isolation, the patient would be asked, “How often do you feel lonely or isolated from those around you?” The selected coding response will reflect the frequency of the patient’s actual or perceived lack of contact with other people.
By following the item-specific guidance related to patient self-report items, agencies can collect and report high-quality data through accurate OASIS collection.