DISCHARGE
ASSESSMENT
INCLUDING OASIS ELEMENTS
DATE  
Follow M00 numbers in sequence unless otherwise directed. QI = Quality Indicator 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: 
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:
First Name:
MI:
Last Name:
Suffix:
Address: (Street/Apt. No.)
City:
State:  Zip Code: 
Secondary Referring Physician I.D.#:
Phone:
First Name:
MI:
Last Name:
Suffix:
(M0020) Patient ID Number:
Medical Record Number if different than M0020
(M0030) Start of Care Date:
(M0032) Resumption of Care Date:
NA - Not Applicable
(M0040) Patients Name:
First Name:
MI:
Last Name:
Suffix:
Patient Phone:
Patient Address:(Street/Apt. No.)
City:
(M0050) Patient State of Residence:
(M0060) Patient Zip Code:
(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:
Patient’s HI Claim No.:
1 - Same as M0063 2 - Same as M0065
3 - Other 
(M0069) Gender: 1-Male2-Female
CLINICAL RECORD ITEMS
(M0080) Discipline of Person Completing Assessment:
1-RN 2-PT 3-SLP/ST 4-OT
(M0090) Date Assessment Completed:
(M0100) This Assessment is Currently Being Completed for the Following Reason:
Discharge from Agency - Not to an Inpatient Facility
9 - Discharge from agency
(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year's influenza season (October 1 through March 31) during this episode of care?
0 - No
1 - Yes [Go to M1050]
NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [Go to M1050]
(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:
1 - Received from another health care provider (e.g., physician)
2 - Received from your agency previously during this year's flu season
3 - Offered and declined
4 - Assessed and determined to have medical contraindication(s)
5 - Not indicated; patient does not meet age/condition guidelines for influenza vaccine
6 - Inability to obtain vaccine due to declared shortage
7 - None of the above
(M1050) Pneumococcal Vaccine: Did the patient receive pneumo coccal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?
0 - No1 - Yes [Go to M1230]
PATIENT NAME - Last, First, Middle Initial
ID#

CLINICAL RECORD ITEMS (Cont�d)
(M1055) Reason PPV not received: If patient did not receive the pneumo coccal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:
  • 1 - Patient has received PPV in the past
  • 2 - Offered and declined
  • 3 - Assessed and determined to have medical contraindication(s)
  • 4 - Not indicated; patient does not meet age/condition guidelines for PPV
  • 5 - None of the above

LIVING ARRANGEMENTS/SUPPORTIVE ASSISTANCE
Primary Caregiver: Patient  
  Caregiver (name)
Phone Number (if different from patient)
Relationship
List name/relationship of other caregiver(s) (other than home health staff) and the specific assistance they give with medical cares, ADLs, and/or IADLs:
Able to safely care for patient
Yes No
Comments:
Other agencies/co-ordination of care:

SENSORY STATUS
(M1230) Speech and Oral (Verbal) Expression of Language (in patient�s own language):
  • 0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.
  • 1 - Minimal difficulty in expressing ideas and needs (may take extra time; makes occasional errors in word choice, grammar or speech intelligibility; needs minimal prompting or assistance).
  • 2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.
  • 3 - Requires considerable assistance in routine situations. Is not alert and oriented or is unable to shift attention and recall directions more than half the time.
  • 4 - Unable to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).
  • 5 - Patient nonresponsive or unable to speak.

PAIN
Intensity: (using scales below)

PAIN (Cont�d.)
No Problem
Is patient experiencing pain?
Yes No
Unable to communicate
Non-verbals demonstrated: Diaphoresis Grimacing
Moaning/Crying Guarding Irritability
Anger Tense Restlessness
Change in vital signs Other:
Self-assessment Implications:
How does the pain interfere/impact their functional/activity level? (explain)
Discharge/on-going plan of care (explain)
Pain Assessment Site 1 Site 2 Site 3
Location
Onset
Present level (0-10)
Worst pain gets (0-10)
Best pain gets (0-10)
Pain description(aching, radiating,throbbing, etc.)
(M1242) Frequency of Pain Interfering with patient�s activity or movement:
  • 0 - Patient has no pain
  • 1 - Patient has pain that does not interfere with activity or movement
  • 2 - Less often than daily
  • 3 - Daily, but not constantly
  • 4 - All of the time
Frequency: Occasionally Continuous Intermittent
What makes pain worse? Movement Ambulation
Immobility Other
Is there a pattern to the pain? (explain)
What makes pain better? Heat/Ice Massage
Repositioning Rest/Relaxation
*** Form still in progress ***