With any stage of care, accuracy within the documentation is key to showing the condition of the patient and the care provided.
The accuracy of the discharge review is just as important as all other OASIS reviews. While accurate documentation begins at the Start of Care (SOC), do not make the mistake of underestimating the importance of an accurate discharge. The discharge OASIS is where you see your outcomes…did they improve or did they drop?
What can you do to ensure an accurate discharge?
Many times, discharge OASIS are not reviewed after the clinician completes the assessment, but as an auditor, I would highly recommend that a certified OASIS reviewer audit the discharge to ensure accuracy.
There is value in having a certified OASIS reviewer audit all SOCs, ROCs, and discharges to ensure accuracy and continuity from beginning to end. Since the reviewer did not lay eyes on the patient, they are looking at the documentation for evidence of conditions and care from a different perspective.
Common mistakes with discharge reviews
This is certainly not all inclusive but here are a couple of common mistakes I see while reviewing documentation.
- SOC is not answered correctly on M1860 stating that a patient can ambulate independently but they require a walker to ambulate safely, then on discharge they are also answered as a 0. The agency will not get a bump for outcomes because there was no improvement noted. The opportunity was missed at SOC when M1860 should have been answered as a 2 and at discharge they are independent, now you see your improvement.
- Intervention synopsis is answered incorrectly at discharge. Many times, I see M2401f (pressure ulcer treatment based on principles of moist wound healing) answered as 0 when in fact the patient did not have a pressure ulcer and the correct response should be NA. If left as a 0, this would show that the patient had a pressure ulcer, but that it wasn’t addressed which hurts the agency outcomes. Having a successful wound care program benefits both patients and agencies.
If you are looking to improve your outcomes and star ratings, start by taking a look at your documentation from SOC to Discharge. Want to talk to someone who can offer resources? Contact our team of experts NOW!
Written by Jessica Cook RN, BSN, HCS-D, COS-C