Unlocked OASIS

Specialties Home Health

Published

My HH Agency recently went from paper to computer charting. One of the things they are requiring is to leave the OASIS unlocked until the coder updates her coding stuff, and they will lock it. What this means to me is that I have to leave my charting vulnerable for anybody (coder, other nurses, or otherwise) to change any of my OASIS data until the eventual point that the coder locks it (usually a week). If we were still on paper what I would equate this to is completing my OASIS on paper in pencil, and signing it in ink. Anyone can come and erase my answers and there may be traces of this but going back and finding out if/whom changed anything is not a simple task. The stupid thing is, even if I do lock my OASIS the coder can simply go in and addend the data which then puts an official time,name,date stamp on the OASIS that proves who did what change. I feel my charting is vulnerable to tampering and have gotten in trouble several times for continuing to lock the OASIS. The main problem is "it's a pain for the coder to make an addendum to the chart". My thought, "Too bad".

COnsequently, my agency has oddly high scores on HH Compare as compared to statewide and regional HH Agencies. Kind of makes me wonder if someone really is tampering with the OASIS data... or maybe I'm paranoid. Am I over reacting about being required to not lock my OASIS?

For the record, "Locking" it means I click a box which puts my name, date, and time on the OASIS and any changes from then on are recorded in the addendum. Changes before locking are not "viewable". Make sense?

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with agencies i have worked for that are computer, it was general practice not to lock the oasis until reviewed....yes the answers can be changed but i have not had an answer changed without being asked....now that being said there is one agency i know of that routinely changes the oasis answers for better outcomes on HH compare.

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I code and I lock the OaSIS. That's a little paranoid. Home care is trust all the way around. Office staff have to trust that visits are really being made on the dates that are stated and that what is being written was actually done. Clinicians have to trust that their work is not being changed. Quite frankly, if I could change anything, it would be the revisit notes. Many people have a difficult time completing those to reflect that skilled care has be delivered. What makes you think your company is doing that and if they are, why not report them, why do you remain?

Continuous locking and unlocking can trigger an audit. It's called teamwork. You are throwing the one having to lock and unlock your OASIS under the proverbial bus. I don't change anything because I've not seen the patient. I don't know your situation or your skill level in completing the OASIS but many agencies have not oriented as well as they should as well as having occasional reviews. I have my nurses select their answers by starting with the last answer and working backward. Remember you are selecting the answer by what YOU OBSERVE the patient doing SAFELY!!!!!! Did you see them put on pants, pullover a shirt, can they read and comprehend?! Always let us know about poor vision, HOH, dribbling is INCONTINENCE!!! Some people are incontinent because they can't get out of the chair and walk to the bathroom quickly enough.

Writing from phone right now but I will post the link from CMS for the chapter that tells how to answer the OASIS. It also states the intent of each questions. We all need to frequently review this info. I've been in the field and I understand.

Home care is a team effort. I first preserve my license and that of my clinicians. I hope things are better than you think they are!

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I have no problems with the OASIS questions at all. I've been doing HH for 3 years. And I also start from the bottom and go up, and consider ability and safety, of course, when choosing an answer. But, thanks for your input.

I cannot say I am in the habit of rechecking my OASIS answers a week later to make sure nobody changed them after it was locked by the coder. I do choose the appropriate diagnoses, but of course the coders know best what order to put them in for best reimbursement, which is why they update it and then lock it. I wish the ICD-9 codes weren't a part of the OASIS let alone on 3 different forms on it. I do trust that's the reason they are requiring us to leave our OASIS unlocked. However, it just seems like a huge liability for ME and MY license to leave an unlocked form. Like I said, it feels like I am leaving a less than indelible record with my permanent signature on it. I do not and will not make the time to go back and recheck my OASIS to make sure it was not tampered with.

And, it is not like the coder has to "unlock" it in order to make their coding changes, they just have to make an addendum which then, quite appropriately, adds their name and date on the OASIS where it belongs if they are the one making the changes. As it is, since it was not locked by the person completing it (me), I am still responsible for any changes that are made whether I am informed of them or not. That seems like more of a red flag for audits to me, than one or two addendums. Leaves the door wide open for fraud. IMHO.

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I don't know your situation or your skill level in completing the OASIS but many agencies have not oriented as well as they should as well as having occasional reviews. I have my nurses select their answers by starting with the last answer and working backward. Remember you are selecting the answer by what YOU OBSERVE the patient doing SAFELY!!!!!! Did you see them put on pants, pullover a shirt, can they read and comprehend?! Always let us know about poor vision, HOH, dribbling is INCONTINENCE!!! Some people are incontinent because they can't get out of the chair and walk to the bathroom quickly enough.

Writing from phone right now but I will post the link from CMS for the chapter that tells how to answer the OASIS. It also states the intent of each questions. We all need to frequently review this info. I've been in the field and I understand.

Home care is a team effort.

Carwin,

The OP was not asking advice on answering the Oasis properly. The subject of this post is having to leave Oasis unlocked and what liability there is with doing so when changes may be made without the nurses consent to do so.

Paddler,

Three weeks ago my company switched computer programs and now we also are not permitted to "lock" are Oasis. I understand that unlocking the Oasis may have red flags, but like you, I don't like leaving my documentation unlocked (Although I have to do it). It goes against nursing 101....write charting in ink, put one line through errors and sign initials. Companies now think with computers that they no longer have to follow basic nursing documentation procedures and I think it's BS as well!

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RN 1263,well aware of the subject, just sharing a little extra knowledge picked up from CMS surveyors.

Whatever is done on ANY computer can be tracked by the IT person and your software vendor. Some software vendors term is a work log which shows who did what on any chart. No one can say they did or didn't. Do something.

We have clinicians sign forms at hire giving permission for correcting the OASIS after a phone call (paper or point of care). The corrections are made after a phone call to the clinician. We complete a correction form and place a copy in the clinicians mailbox and personnel file. RN 1263, reviewing those forms allows me to see which questions are a problem (widespread or individual)and I can address that in a staff mtg or 1:1.

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I realize there are keystroke programs and such that can track who touched the chart and when and even what they did. However, in these cases you have to know to go look for the information. It is not up front and readily viewable in the chart like simply making an addendum would be. It allows for hidden things to go on. I know personally I cannot look at this information.

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We have clinicians sign forms at hire giving permission for correcting the OASIS after a phone call (paper or point of care). The corrections are made after a phone call to the clinician. We complete a correction form and place a copy in the clinicians mailbox and personnel file.

With our new software we have "follow-up notification" from Clinical managers via computer. They are suppose to let us know what has been changed or ask us to change an item, mark severity codes, then lock note and Oasis. We've been on the new system for 3 weeks and every Oasis follow-up notification I've gotten back to lock has said "Mark severity codes, lock SN note and Oasis".

So, either I am that good where NO changes have needed to be made OR they are making changes and not notifying or asking me..... I bet there making changes, cuz, I'm good, but not perfect and I'm sure SOMETHING has needed changed???:rolleyes:

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