Re: OASIS and HOME HEALTH CHARTING, how to do it.
I'm not sure exactly what you are looking for. I know the QA department gives frequent in-services to our clinical staff. One thing I do know is that it is important that your charting always reflects skilled need. Otherwise medicare may decide not to pay because there was no skilled need reflected. This is easy to do for things like wound care, catheter management and IV medications. But for patients where you do more assessing and teaching instead of skills it gets a little murky.
At the hospital we primarily chart what we see. But in home care you have to go beyond that since what you see may not indicate medical necessity for home care services. Always use "Pt
instructed in______" Whether they understand or not. If not, indicate "further teaching required"
For the OASIS assessment itself we were given a book Instant OASIS Answers 2008 to refer to so you could properly answer the Q's. Although I don't use much. I just learned from way-to-frequent phone calls from QA how to better answer the questions.
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