Have you ever?

[Willow Moonsidhe]

Have any of you ever been asked to change answers because a computer program the company has did not agree with your answers?

Thanks

~Willow

[RubyRN,CHPN]

Are you speaking of OASIS assessment answers?

[Willow Moonsidhe]

Yes, I thought that was illegal?

[RubyRN,CHPN]

Our computer program doesn't ask us to change answers based on some kind of conflict within the system. We are required to validate assessments before we do an electronic signature which might catch a wrong date, missing information, etc. We do have a QA department which has some sort of standardized review of each admit, ROC, RC which might look at our assessment and suggest a better way to answer a question based on the assessment as a whole; but they never make us change something we know to be true. I feel lucky to know I've got someone who has my back. Our QA nurses are OASIS certified.

Our computer program does tell us at recert time if a pt. has experienced a functional decline in an ADL and how the question was answered last time OASIS data was collected; maybe this serves two purposes-for outcomes and pay for performance. Especially with those tricky OASIS wound questions. Might bear the clinician double checking with other discipline what they observed at discharge. Once again, computer would not tell use to change an answer.

Agency/health system I work for frowns highly on upcoding which is fraud and abuse. We are required to report misrepresentations including upcoding to an integrity line. We are responsible for making our own changes to OASIS since computer notes any changes by who made them to assessments.

[Willow Moonsidhe]

I just told them the questions were answered honestly. I am not sure what else to do. It sure did make me feel uncomfortable. I felt like saying if the computer can assess from the office why not send it on the road lol. I think people might be able to manage one ADL at a higher level than another. Just my thoughts though.

[KateRN1]

Willow, I know you're new at this, so please take my response as a teaching tool. Use it if it applies, and if it doesn't, then disregard.

Unfortunately, many nurses who are new to home health care and OASIS don't get a good foundation in the assessments and make some typical rookie mistakes. Then they don't understand why they are being asked to change their answers. And it does take a while to get really comfortable with the whole thing and understand what the questions are asking you. The whole point is to paint a clear picture of the patient's clinical, functional, and service levels. In my experience, the functional scores are the hardest for nurses to really do well. (At least with version C we don't have to score them for 14 days prior to SOC anymore!)

As part of your assessment, you should be asking the patient to perform a few tasks, such as: walk to the kitchen, walk to the bathroom, get in and out of the shower, sit on the toilet and get up again, and walk to the bedroom and lie down on the bed.

If your patient is non-ambulatory, then this is obviously not applicable. However, for those who have gait or balance instability, you will get a wealth of information from this bit of assessment.

Some of the OASIS answers that I routinely challenge are as follows:

1. Patient ambulates with a walker at all times, yet is independent in showering or dressing, transfering, etc.

2. Patient is on O2 at 3lpm continuous, is dyspneic with min exertion or at rest, and is independent in all ADLs.

3. Patient is incontinent with diapers but Braden scale is marked as "only requires linen change daily." (Not an OASIS question, but still irks me.)

4. Patient's respiratory status must be observed by the nurse when at all possible. Patients who are on oxygen are most likely short of breath. If they have oxygen therapy, don't put that they are never short of breath. It's almost impossible.

5. Transfering--if the patient pushes up on the arms of the chair or uses the table to grab onto to rise, that's "with an assistive device."

6. Ambulating--if the patient grabs furniture and walls, that's using an assistive device and isn't considered safe. If the patient can't negotiate stairs, they're not independently ambulating.

Incorrect documentation of wounds is another issue that I see frequently.

The key to documentation with functional abilities is to consider the all-important word safely. Can the patient do the activity safely? Can the patient tie shoes, pull on undergarments, button buttons, zip zippers, etc.? If the only way for the patient to be truly safe is if all is done with assistance and there's no assistance available, don't take the lack of assistance into consideration. Mark what is safe for the patient.

Example:

Mrs. Jones walks with a walker due to balance issues, but leaves it in the hallway to go to the bathroom, where she uses the towel bar to help her get on and off the potty. She wears pads for incontinence, which she keeps on the back of the toilet tank because she can't reach the shelves in the closet. She uses the towel bar to hold onto to get in and out of the tub because she doesn't have grab bars, but most days she just sponges off at the sink as much as she can reach. She is able to dress herself, but it takes a lot of effort and she only wear slip-on shoes because she can't bend over to tie them. She doesn't wear socks because she can't get them on. She keeps most of the clothes that she wears thrown over the back of a chair because she can't reach the closet shelves using her walker. She can reheat microwave meals, but because her refrigerator is on the other side of the kitchen from her microwave, she has a hard time getting the meal to the microwave to heat it. She is unable to get pots and pans out to cook as she can't reach them.

Based on this scenario, I would score her functionals this way:

*M1800-grooming--(1) grooming utensils must be placed within reach

*M1810-ability to dress upper body--(1) able to dress upper body without assistance if clothing is laid out or handed

*M1820-ability to dress lower body--(2) someone must help patient put on

*M1830-bathing--(3) requires the assistance of another person (a) to get in and out of tub

*M1840-toilet transferring--(1) when reminded, assisted, or supervised by another person

*M1845-toileting hygiene--(1) able to manage if supplies are laid out

*M1850-transferring--(1) human assistance or device

*M1860-ambulation--(2) requires 2-handed device

*M1870-eating--(0) independent, she can chew and swallow without difficulty

*M1880-ability to prepare meals--(2) unable to prepare meals

What are the specific assessements you were asked to change? Do your responses paint a true picture of the patient's status?

[Willow Moonsidhe]

I have watched the videos on Oasis and thought I had a pretty good grasp. There is a big push to see progress and to score on worse side than better so in the end it looks like head way on function and wound stats; sometimes I agree and other times I don't if that makes sense. Some patients try to do more than they safely can I can see scoring that a little more on the high side. I can see scoring a decub you are unsure of one step further; especially if it probably has underlying damage and you come back to a big messy decub 2 days later. It just feels like they are ganging up on me. I nearly snapped today over all the changes. Especially when they tried to take an unstable CHF patient's SNV away with her on PT/INR's and unstable coumadin changes just because she lost her doctor. I had already helped her call a new doctor and had an appointment for her on Friday because I was worried about her. I guess I have the unfortunate disease of really giving a ______ about the patient's more than anything. That seems to always keep me in the frying pan. Thanks for the help. It did clear up some of the things they are doing.

Blessings

~Willow

[caliotter3]

Kate gave an excellent picture of properly using the OASIS. I am sorry to hear that you are having such troubles with your cases and the people you are working with. Be careful so as not to poison the job atmosphere for yourself. Maybe take a day or two off to try to recuperate once in awhile. Not saying you are wrong, but even if you are 1000% correct, when the others gang up on you, you will only lose in the end. Don't lose your cool or your job over it.

[Willow Moonsidhe]

Thanks for the advice it is much appreciated. I am tired and that does not help.

~Willow

[KateRN1]

Willow, another thought. As I review charts, I am keenly aware that I am not seeing the patient with my own eyes, but through the eyes of another clinician who may have more or less experience than me, whether it be nursing experience, home health experience, etc. One of the things that helps is when you write notes that I can use to paint a better picture. While the OASIS questions give a very cookie-cutter picture, it's up to the narrative note to paint the rest of the picture. Consider a typical American subdivision of homes--think of the OASIS framework as the structure of the house and the narrative to be the furnishings, that which gives it individuality. Personalize as much as you can to help others see the patient the way you do.

[KateRN1]

And take a day off. It sounds like you need it.