COMPREHENSIVE ADULT
NURSING ASSESSMENT
INCLUDING SOC/ROC OASIS ELEMENTS
WITH CMS 485 INFORMATION
Follow M0 numbers in sequence unless otherwise directed. QI = Quality Indicator DATE  
REASON FOR ASSESSMENT:
Start of Care
Resumption of Care
TIME IN   TIME OUT  
This Patient Tracking Information must be filled out at start of care and per organizational policy.
It is to be maintained as part of the clinical record.
(M0010) CMS Certification Number: (Locator #5)  
Branch Identification       (M0014) Branch State:

(M0016) Branch ID Number:
(M0018) National Provider Identifier (NPI) for the attending physician who has signed the plan of care:
UK - Unknown or Not Available
Phone:(Locator #24)
First Name:(Locator #24)
MI:
Last Name:
Suffix:
Address: (Street/Apt. No.)(Locator #24)
City:(Locator #24)
State: (Locator #24) Zip Code: (Locator #24)
Secondary Referring Physician I.D.#:
Phone:
First Name:
MI:
Last Name:
Suffix:
(M0020) Patient ID Number:(Locator #24)
Medical Record Number if different than M0020
(M0030) Start of Care Date:(Locator #2)
(M0032) Resumption of Care Date:
NA - Not Applicable
(M0040) Patients Name:(Locator #6)
First Name:
MI:
Last Name:
Suffix:
Patient Phone:
Patient Address: (Street/Apt. No.)(Locator #6)
City:
(M0050) Patient State of Residence: (Locator #6)
(M0060) Patient Zip Code: (Locator #6)
(M0063) Medicare Number:
NA - No Medicaree
(including suffix)
(M0064) Social Security Number:
UK - Unknown or Not Available
(M0065) Medicaid Number:
NA - No Medicaid
(M0066) Birth Date: (Locator #8)
Patient’s HI Claim No.: (Locator #1)
1 - Same as M0063 2 - Same as M0065
3 - Other 
(M0069) Gender: (Locator #9) 1-Male2-Female
Emergency Triage Code:
DNR Order: ObtainedRequested
(M0140) Race/Ethnicity: (Mark all that apply.) (M0150) Current Payment Sources for Home Care: (Mark all that apply.)
1 - American Indian of Alaska Native
0 - None; no change for current services
2 - Asian
1 - Medicare (traditional fee-for-service)
3 - Black or African-American
2 - Medicare (HMO/managed care/Advantage plan)
4 - Hispanic or Latino
3 - Medicaid (traditional fee-for-service)
5 - Native Hawaiian or Pacific Islander
4 - Medicaid (HMO/managed care)
6 - White
5 - Workers’ compensation
6 - Title programs (e.g., Title III, V, or XX)
7 - Other government (e.g., TriCare), VA, etc.
8 - Private insurance
9 - Private HMO/managed care
Certification Period:     (Locator #3)
10 - Self-pay
From         To  
11 - Other (specify)
UK - Unknown
 
 
 
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