OASIS Documentation for Dummies

by Keith Grunig

Nurse Completing Medical Assessment


In any profession, documentation is important.  In Home Health, it's essential.  Quality documentation can mean the difference between full payment, ADR, denials, or worse.  With CMS enacting at RCD (Review Choice Demonstration) and continued Targeted Probe and Educate, success largely depends on documentation.  

As an agency, we have handled thousands of ADRs.  We have great auditors that help agencies with ADR (Additional Documentation Requests) for agencies.  Our auditors are experts in their field- former employees of Palmetto GBA or former agency owner, PT, and expert in denials appeals, and ADR review.  

In this post we'll go over what is necessary documentation (OASIS Documentation for Dummies), but also, we'll explain what can be done to help agencies be successful, avoid continued issues, and improve reimbursement.


Here are the key components necessary for documentation for OASIS.  This material is used with permission from a presentation by Ed Dieringer, PT.  Ed has owned home health agencies, is a PT, and has developed a specialty in ADR (additional documentation request) and ADR appeals.  

1.Initial Referral Order(s) and Physician Face to Face Visit Clinical Record- MUST BE SIGNED BY PHYSICIAN AND BE RELATED TO PRIMARY DIAGNOSIS.  CMS has allowed that Nurse Practitioners, Physicians Assistants, and Certified Nurse Specialist may sign plans of care and Face to Face.  Please check state practice acts as this can vary by state.  

2.Accurate OASIS Data Sets (SOC, ROC, Recert, Discharge)- This affects how much agency gets paid.  Accuracy is parament.  

3.Initial Comprehensive Assessment- Narrative supports the why as to the medical necessity of care.  Does OASIS match the actual condition of the patient?  Patients want to appear better than they actually are.  

4.Physician Certified 485 - Plan(s) of Care- 

  • Brings together all critical issues and discipline POC into one document for physician certification.
  • F2F, Homebound, 60-day episode, Primary Dx, multimorbidities,
  • Lists treatment plans and goals for all services.  SHOULD BE PATIENT CENTERED and relevant to patient to be successful.  
  • Clinical summary of patient’s unique and complex issues justifying medically reasonable and necessary home health services as outlined to assure medical/functional safety and to optimize functional outcomes.
  • Physician Office Contact with Verbal Order dated on or day after SOC date to assure all services covered between SOC and physician signature date.

5.Therapy Assessment (Initial)

  1. Therapy Evaluation - Tell The Story in Skilled Terms

Unskilled:  Gait training required SBA w/FWW x 50 feet, ModA with Sit to/from Stand transfers.

An aide could tell the reader this info. 

A Reviewer still needs to know THE WHY – What is the actual problem in skilled terms

Dust off that brain that you spent a ton of money and many years of school to learn the hundreds of components that make up any functional task and its relationship to specific environments.


Gait: shuffling, stubs toe, lack of dorsi flexion, low foot clearance, decreased stance time, minimal swing through, no toe off, shortened terminal stance time, stagger on turns requiring moderate assistance to remain standing, can the patient do more than one thing at a time – key to functional gait.

Transfers: What is Motor control/grading of muscle contraction to sit down safely, body mechanics, gets to edge of chair, uses arm rests? Need raised height or other environmental adaptations? Upon standing does patient waiver, spread arms, grab onto walker, toilet/bath transfer – caregiver body mechanics to assist

Dynamic Balance: Ability to self-correct to remain upright during challenges to balance – Hundreds of components.

Pain: When? Where? Intensity? Acute or Chronic? Test  ****DOES THIS MATCH M1242****

Skilled testing should relate to the goal to be achieved – If patient is currently walking with walker, but goal is to use cane as prior to injury – test gait ability with cane. 

6.Complete and Skilled Daily Visit Notes

  • Set New Standards of Practice Using Skilled Assessment Language
  • Assessment (Determining what has gone on since last visit that influence today’s visit)
  • Treatment = Listed standards – What was focus / How Instructed
  • Assessment (Measuring response to instruction/treatment)
  • Promoting independence with assigning practice/homework

7.Therapy Re-Assessment (30 day & Recert/DC)

  1. Create an updated problem list in skilled terms to demonstrate the continuing need for skilled intervention.
  2. Speak to upgrading HEP to meet patient’s new functional level.
  3. THE WHY - Why is it Medically Necessary and reasonable to continue care?
  4. Why is it important that only PT can treat and not person of lesser skill?
  5. Changes to Treatment frequency and duration or continue.
  6. Expect continued progress based on past progress, resolution of more basic goals, Reasonableness of expected outcomes and need for longer than expected intervention.

Planning Recert or continuing beyond 30 days - Not enough to say, “not met goals” or “progressing well.”

Example of Medically Necessary Statement: “Medically complex patient’s confusion/pain slowed initiation of full plan of care and so took longer than expected to gain meaningful progress in goals.  She still suffers from / exhibits (Problem List) that requires the skills of a physical therapist to assure her continued and safe progress toward her goals of safe mobility to perform indep ADLs, ambulation about facility such as dining, community activities, and to exit the building safely in a timely manner in case of emergency or to attend physician’s appointment.  It is reasonable to expect patient to meet goals based on her recent progress after initial set back.

Continue next 30 days or Recertify PT for [Frequency, duration, new treatments, new goals].” 

For Planned discharge – not enough to say “goals met.” 

Example of DC Statement –

“Patient shows stabilization in goals and is considered safe for discharge with caregiver support.” 

“Due to pt’s medical complexities, considerable risk for falls or sudden decline, and lack of regular caregiver, PT will expect to discharge after assuring medical/functional stabilization and adherence to HEP for long term outcomes.”

Issue NOMNC – Inform about Appeal option

Get physician VO for changes to POC, Recert, DC. 


Summary- adequate documentation is a great insurance against denials.  An auditor only has the documentation available to make a determination on denials/ADR.  Coding is only as good as the documentation available.  Coding, really, is painting a picture in code form of the condition of the patient at the time of assessment.  


We know that even with the best documentation, ADRs can and do come.  In another blog post, we wrote about ADRs and how to handle them.  You can read it What is an ADR in Home Health?  In it, we provide links to the ADR checklist from the MACs.  We have included those links here, and an easy checklist for home health and hospice below as well from CGS

NGS ADR Checklist

CGS ADR Checklist (Home Health and Hospice)

Palmetto GBA ADR Checklist


Here are the CGS Checklists. We thought they were the most concise

Home Health ADR Checklist – Preferred Order

1.    FISS Page 7 screenprint

2.    Physician Face-to-Face documentation

a. Actual encounter note or progress note

b. Discharge summary from inpatient stay

3.    Plan of care with physician certification/recertifications

a. If recertification, include initial certification

4.    Interim/verbal orders

5.    OASIS assessment

6.    Nursing visit notes

7.    Therapy visit notes including evaluations/re-evaluations

8.    Social work visit notes

9.    Aide visit notes

10.  Other relevant documentation

a. Acute/post-acute care documentation to support home health eligibility.



Hospice ADR Checklist – Preferred Order

1.    FISS Page 7 screenprint

2.    Signed election statement

3.    Plan of care with physician certification/recertifications

4.    Physician Face-to-Face documentation (for third and later benefit periods)

5.    Physician orders

6.    IDG reviews/POC updates


Note: include reviews for each 15-day period to cover the billing period. This may include reviews/updates that occurred prior to the billing period.

7.    Admission initial assessment

8.    Visit notes (nursing, social worker, chaplain, etc.)

9.    Physician visit notes

10.  Other relevant documentation



It is said that if you are prepared you won't fear.  Documentation is some of the best preparation you can do.  Then make sure everything else is in a row and you'll be ready.  Our staff has handled thousands of ADRs before.  We can help with the QA of documentation to ensure you're ready to go.  Paying a little for peace of mind is worth the cost.


Here is a great short video from CMS on the importance of documentation.

CMS Documentation Recap

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