Discharge Oasis

M0040. Patient Name

First NameMiddle InitialLast NameSuffix
M0080. Discipline of Person Completing Assessment
1. RN 2. PT 3. SLP/ST 4. OT
M0090 Date Assessment Completed

MonthDayYear
M0100. This Assessment is Currently Being Completed for the Following Reason
4. Recertification (follow-up) reassessment 6. Transferred to an inpatient facility 8. Death at home 9. DISCHARGE FROM AGENCY
M0906 Date of the discharge, transfer, or death (at home) of the patient.

MonthDayYear
M2301. Emergent Care . At any time since the most recent SOC/ROC assessment has the patient utilized a hospital emergency department (includes holding/observation status)?
0) No 1) Yes / without hospital admission 3)Yes/ with hospital admission
M2310. Reason for Emergent Care

M2420. Discharge Disposition Where is the patient after discharge from your agency?
1) Remained in community without skilled services 2) Remained in community with skilled Services 3) Transferred to hospice 4) Unknown
M2410. To which Inpatient Facility has the patient been admitted?
1) Hospital 2) Rehab Facility 3) Nursing Home 4) Hospice 5) N/A
A2121. At the time of discharge to another provider, did your agency provide the patient's current reconciled medication list to the subsequent provider, family, and/or caregiver?
0) No 1) Yes
A2122. Route of Current Reconciled Medication List Transmission to Subsequent ProviderIndicate the route(s) of transmission of the current reconciled medication list to the subsequent provider
A2124. Route of Current Reconciled Medication List Transmission to Subsequent Provider.Indicate the route(s) of transmission of the current reconciled medication list to the subsequent provider
A2123 At the time of discharge, did your agency provide the patient's current reconciled medication list to the patient, family, and/or caregiver?
0) No 1) Yes
B1300. Health Literacy (From Creative Commons How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?
0. Never 1. Rarely 2. Sometimes 3. Often 4. Always 7. Patient declines to respond 8. Patient unable to respond

C0100. Should Brief Interview for Mental Status (C0200-C0500) be Conducted? Attempt to conduct interview with all patients.
0. No ( C1310) 1. Yes → Continue to C0200
Brief Interview for Mental Status (BIMS)
C0200. Repetition of Three Words Ask patient: "I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue, and bed. Now tell me the three words. "Number of words repeated after first attempt:
0. None 1. One 2. Two 3. Three
C0300. Temporal Orientation (Year) Ask patient "Please tell me what year it is right now..
0. Missed by > 5 years or no answer 1. Missed by 2-5 years 2. Missed by 1 year 3. Correct
C0300. Temporal Orientation (Month) Ask patient: "What month are we in right now?"
0. Missed by > 1 month or no answer 1. Missed by 6 days to 1 month 2. Accurate within 5 days
C0300. Temporal Orientation (Day) Ask patient: "What day of the week is today?"
0. Incorrect or no answer 1. Correct
C0400 Recall Ask patient " Let's go back to earlier question. What were those three words that I asked you to repeat?" If unable to remember a work , give a cue(something to wear, a color , a pierce of furniture for the word. . A. Able to recall "sock"
0) No 1) Yes, after cueing 2) Yes - no cue required
B . Able to recall "Blue"
0) No 1) Yes, after cueing 2) Yes - no cue required
C . Able to recall "Bed"
0) No 1) Yes, after cueing 2) Yes - no cue required
C0500. BIMS Summary Score
Add scores for questions C0200-C0400 and fill in total score (00-15)Enter 99 if the patient was unable to complete the interview
C0500. BIMS Summary Score

C1310 Signs and Symptoms of Delirium A. Acute onset of mental status change
0 . No 1. Yes
B. Inattention – Did the patient have difficulty focusing attention, for example, being easily distractible or having difficulty keeping trackof what was being said?
0. Behavior not present 1. Continuously present 2. Fluctuates
C. Disorganized thinking – Was the patient’s thinking disorganized orincoherent (rambling or irrelevant conversation, unclear or illogicalflow of ideas, or unpredictable switching from subject to subject)?
0. Behavior not present 1. Continuously present 2. Fluctuates
D. Altered level of consciousness — Did the patient have altered level of consciousness, as indicated by any of the following criteria?• vigilant — startled easily to any sound or touch• lethargic — repeatedly dozed off when being asked questions
0. Behavior not present 1. Continuously present 2. Fluctuates
M1700. Cognitive Functioning Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.
0. Alert/oriented, no prompting 1. Requires prompting under stressful or unfamiliar conditions. 2. Requires assistance and some direction in specific situations 3. Requires considerable assistance in routine situations. 4. Totally dependent
M1710 . When Confused (Reported or Observed Within the Last 14 Days)
0. Never 1. New or complex situations only 2. On awakening or at night only 3. During the day and evening; not constantly 4. Constantly NA Patient nonresponsive
M1720 When Anxious (Reported or Observed Within the Last 14 Days):
0. None of the time 1. Less than often daily 2. Daily, but not constantly 3. All of the time NA Patient nonresponsive

D0150. Patient Mood Interview (PHQ-2 to 9)

Symptom Presence: 0. No

Rows	Symptom Presence	Symptom Frequency
Symptoms Presence 0. No 1. Yes 9. No response
Symptoms Frequency 0. Never 1. 2-6 days 2. 7-11 days 3. 12-14 days
A. Little interest or pleasure in doing things
B. Feeling down, depressed, or hopeless
C. Trouble falling or staying asleep, or sleeping too much
D. Feeling tired or having little energy
E. Poor appetite or overeating
F. Feeling bad about yourself - or that you are a failure or have let yourself or your family down
G. Trouble concentrating on things, such as reading the newspaper or watching television
H. Moving or speaking so slowly that the other people could have noticed. Or the opposite - - being so fidgety or restless that you have been moving around a lot more than usual
I. Thoughts that you would be better off dead, or of hurting yourself in some way

D0160. Total Severity Score Add scores for all frequency responses in Column 2, Symptom Frequency. Total score must be between 00 and 27. Enter 99 if unable to complete interview (i.e., Symptom Frequency is blank for 3 or more required items)
D0160. Total Severity Score Add scores for all frequency responses in Column 2, Symptom Frequency. Total score must be between 00 and 27. Enter 99 if unable to complete interview (i.e., Symptom Frequency is blank for 3 or more required items)

D0700. Social Isolation
How often do you feel lonely or isolated from those around you?
0. Never 1. Rarely 2. Sometimes 3. Often 4. Always 7. Patient declines to respond 8. Patient unable to respond
Section E | Behavior
M1740. Cognitive, Behavioral, and Psychiatric Symptoms that are demonstrated at least once a week (Reported or Observed): Check all that apply
M1745. Frequency of Disruptive Behavior Symptoms (Reported or Observed):Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.
0. Never 1. Less than once a month 2. Once a month 3. Several times each month 4. Several times a week 5. At least daily

M2102. Types and Sources of Assistance
Determine the ability and willingness of non-agency caregivers (such as family members, friends, or privately paid caregivers) to provide assistance for the following activities, if assistance is needed. Excludes all care by your agency staff.
a. ADL assistance (for example, transfer/ambulation, bathing, dressing, toileting, eating/feeding)
0. No assistance needed 1. Non-agency caregivers currently provide assistance 2. Non-agency caregiver(s) need training 3. Non-agency caregiver(s) not likely to provide assistance 4. Assistance needed, but non-agency caregivers unavailable
c. Medication administration (for example, oral, inhaled, or injectable)
0. No assistance needed 1. Non-agency caregiver(s) currently provide assistance 2. Non-agency caregiver(s) need training 3. Non-agency caregiver(s) not likely to provide assistance 4. Assistance needed, but no non-agency caregiver(s) available
d. Medical procedures/treatments (for example, changing wound dressing, home exercise program)
0. No assistance needed 1. Non-agency caregiver(s) currently provide assistance 2. Non-agency caregiver(s) need training 3. Non-agency caregiver(s) not likely to provide assistance 4. Assistance needed, but no non-agency caregiver(s) available
f. Supervision and safety (due to cognitive impairment)
0. No assistance needed 1. Non-agency caregiver(s) currently provide assistance 2. Non-agency caregiver(s) need training 3. Non-agency caregiver(s) are not likely to provide assistance 4. Assistance needed, but no non-agency caregiver(s) available
Section G | Functional Status
M1800. Grooming Current ability to tend safely to personal hygiene needs
0. Able to groom unaided, with/ without assistive devices . 1. Grooming utensils must be placed within reach 2. Someone must assist the patient 3. Patient depends entirely upon someone else
M1810. Current Ability to Dress Upper Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps.
0.No assistance 1. No assistance with set up 2. Assistance needed 3. Dependent
M1820. Current Ability to Dress Lower Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes.
0.No assistance 1. No assistance with set up 2. Assistance needed 3. Dependent

M1830. Bathing Current ability to wash entire body safely. Excludes grooming (washing face, washing hands, and shampooing hair).
0. Independent 1. Independent With devices 2. Intermittent assistance 3. Constant Assistance 4. Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode. 5. Unable to use the shower or tub, but able to participate in bathing with assistance 6. Total assist
M1840. Toilet Transferring Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.
0. Independently with or without a device. 1. Needs reminder, assistance, or supervision 2. Able to use a bedside commode 3. Able to use a bedpan/urinal independently. 4. Totally dependent in toileting.
M1845. Toileting Hygiene Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, includes cleaning area around stoma, but not managing equipment.
0. No assistance 1. No assistance with set up 2. Assistance needed 3. Dependent
M1850. Transferring Current ability to move safely from bed to chair, or ability to turn and position self in bed if patient is bedfast.
0. Independent 1. Minimal assistance or with use device. 2. Extensive assistance 3. Total Assist 4. Bedfast, able to turn and position self in bed. 5. Bedfast, unable to turn and position self.
M1860. Ambulation/Locomotion Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.
0. Independently walk/ negotiate stairs 1. Independently walk/ negotiate stairs with the use of a one-handed device 2. Independently walk with two-handed device and/or requires assistance to negotiate stairs or uneven surfaces. 3. Supervision/assistance required 4. Chairfast, but able to wheel self. 5. Chairfast, unable to wheel self.

GG0130. Self-Care
Code the patient's usual performance at Discharge for each activity using the 6-point scale. If activity was not attempted at Discharge, code the reason.

Coding:
Safety and Quality of Performance – If helper assistance is required because patient's performance is unsafe or of poor quality, score according to amount of assistance provided.
Activities may be completed with or without assistive devices.
    06. Independent – Patient completes the activity by themself with no assistance from a helper.
    05. Setup or clean-up assistance – Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.
    04. Supervision or touching assistance – Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently.
    03. Partial/moderate assistance – Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort.
    02. Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.
    01. Dependent – Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity.
If activity was not attempted, code reason:
    07. Patient refused
    09. Not applicable – Not attempted and the patient did not perform this activity prior to the current illness, exacerbation or injury.
    10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
    88. Not attempted due to medical conditions or safety concerns
A. Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient.
B. Oral Hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from mouth, and manage denture soaking and rinsing with use of equipment.
C. Toileting Hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment.
E. Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower.
F. Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable
G. Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear.
H. Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable.

GG0170. Mobility
Code the patient's usual performance at Discharge for each activity using the 6-point scale. If activity was not attempted at Discharge, code the reason.

Coding:
Safety and Quality of Performance – If helper assistance is required because patient's performance is unsafe or of poor quality, score according to amount of assistance provided.
Activities may be completed with or without assistive devices.
- 06. Independent – Patient completes the activity by himself with no assistance from a helper.
- 05. Setup or clean-up assistance – Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.
- 04. Supervision or touching assistance – Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently.
- 03. Partial/moderate assistance – Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort.
- 02. Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.
- 01. Dependent – Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity.
If activity was not attempted, code reason:
- 07. Patient refused
- 09. Not applicable – Not attempted and the patient did not perform this activity prior to the current illness, exacerbation or injury.
- 10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
- 88. Not attempted due to medical conditions or safety concerns
A. Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed.
B. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.
C. Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed with no back support.
D. Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed.
E. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair).
F. Toilet transfer: The ability to get on and off a toilet or commode.
G. Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt.

I. Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. If Discharge performance is coded 07, 09, 10 or 88 -> Skip to GG0170M, 1 step (curb)
J. Walk 50 feet with two turns: Once standing, the ability to walk 50 feet and make two turns.
K. Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space.
L. Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel.
M. 1 step (curb): The ability to go up and down a curb or up and down one step. If Discharge performance is coded 07, 09, 10 or 88 -> Skip to GG0170P, Picking up object.
N. 4 steps: The ability to go up and down four steps with or without a rail. If Discharge performance is coded 07, 09, 10 or 88 -> Skip to GG0170P, Picking up object.
O. 12 steps: The ability to go up and down 12 steps with or without a rail.
P. Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor.
Q. Does patient use wheelchair and/or scooter?
0. No -> Skip to M1600, Urinary Tract Infection 1. Yes -> Continue to GG170R, Wheel 50 feet with two turns
R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns.
RR1. Indicate the type of wheelchair or scooter used
1. Manual 2. Motorized
S. Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space.
SS1. Indicate the type of wheelchair or scooter used
1. Manual 2. Motorized

M1600. Has this patient been treated for a Urinary Tract Infection in the past 14 days?
0. No 1. Yes NA Patient on prophylactic treatment UK Unknown [Omit “UK” option on DC]
M1620. Bowel Incontinence Frequency
0. Very rarely or never 1. Less than once weekly 2. 1-3x/ week 3. 4-6x / week 4. On a daily basis 5. More often than once daily NA Ostomy
J0510. Pain Effect on Sleep Ask patient: "Over the past 5 days, how much of the time has pain made it hard for you to sleep at night?
0. Does not apply — I have not had any pain or hurting in the past 5 days → Skip to M1400, Short of Breath at SOC/ROC; Skip to J1800, Any Falls Since SOC/ROC at DC 1. Rarely or not at all 2. Occasionally 3. Frequently 4. Almost constantly 8. Unable to answer
J0520. Pain Interference with Therapy Activities Ask patient: "Over the past 5 days, how often have you limited your participation in rehabilitation therapy sessions due to pain?"
0. Does not apply — I have not had any pain or hurting in the past 5 days → Skip to M1400, Short of Breath at SOC/ROC; Skip to J1800, Any Falls Since SOC/ROC at DC 1. Rarely or not at all 2. Occasionally 3. Frequently 4. Almost constantly 8. Unable to answer
J0530. Pain Interference with Day-to-Day Activities Ask patient: "Over the past 5 days, how often you have limited your day-to-day activities (excluding rehabilitation therapy sessions) because of pain?"
1. Rarely or not at all 2. Occasionally 3. Frequently 4. Almost constantly 8. Unable to answer
J1800. Any Falls Since SOC/ROC, whichever is more recent
No → Skip to M1400, Short of Breath at DC; Skip to M2005 Yes → Continue to J1900, Number of Falls Since SOC/ROC

J1900. Number of Falls Since SOC/ROC, whichever is more recent Coding: 0. None 1. One 2. Two or more

Rows	Enter code in boxes
A. No injury: No evidence of any injury is noted on physical assessment by
B. Injury (except major):
C. Major injury

M1400. When is the patient dyspneic or noticeably Short of Breath?
0. Not short of breath 1. When walking 20+ feet, climbing stairs 2. With moderate exertion 3. With minimal exertion 4. At rest (during day or night)

Rows	Last 7 days	At discharge
A. Parenteral/IV feeding
B. Feeding tube (e.g., nasogastric or abdominal (PEG))
C. Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food, thickened liquids)
D. Therapeutic diet (e.g., low salt, diabetic, low cholesterol)
Z. None of the above

Rows	No	Yes	Not Applicable
b. Falls prevention interventions
c. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment
d. Intervention(s) to monitor and mitigate pain
e. Intervention(s) to prevent pressure ulcers
f. Pressure ulcer treatment based on principles of moist wound healing

Brief Interview for Mental Status (BIMS)

D0150. Patient Mood Interview (PHQ-2 to 9)

D0700. Social Isolation

Section E | Behavior

Section G | Functional Status

GG0130. Self-Care

N0415. High-Risk Drug Classes: Use and Indication

Section Q | Participation in Assessment and Goal Setting