4 Things Killing Your OASIS Assessment and How to Fix Them | rnventingnursing.com

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home health nurse

OASIS Assessment Mistakes

OASIS Documentation Tips

4 Things Killing Your OASIS Assessment and How to Fix Them


Your OASIS assessment can have 137 million mistakes…

No Really…complete true story…

From your scheduling call…to your prep work…to how you complete your patient’s assessment…

If you’re finding it hard to get your OASIS assessments approved on the first try….

Or if you’re not getting any helpful guidance or feedback from your OASIS reviewers

Or if you’re finding it crazy difficult to write your OASIS nursing narrative notes

Or you’re just plain stuck as it pertains to OASIS assessments and documentation as a whole, you may unknowingly be making one or more of the 4 mistakes that we’re going to cover in today’s blog post.

Several of these mistakes are simple enough to rectify and may just be flying under your radar causing more frustration than you could ever give them credit for.

But the best part of all of this is that…they’re not difficult to correct!

If you think your OASIS assessment strategy could use some work, just sign-up for my free OASIS Follow-Up Assessment Cheat Sheet™ by clicking the button below, where I give you a cheat sheet that will take your OASIS assessment process from “Where is that piece of paper that I…Shiz, I forgot to ask that question” to “Your submitted OASIS assessment for Jane Healthy has been approved”.

After reading today’s post, you will walk away with gems of knowledge about:

  • A proven OASIS assessment process that can rectify all of your assessment and documentation woes,
  • 4 key elements to crafting a perfect OASIS nursing narrative note, and
  • The EASIEST tool to craft your OASIS nursing narrative note (you can do it in less than an hour!) that helps more than 1k home health nurses shrink their documentation time and resubmissions while advancing their careers and protecting themselves. 


Before we dive into this post, let’s take a quick look at the entire OASIS Assessment and Documentation Process.

The diagram below outlines my signature flow and planning process that OASIS documentation can follow starting with your Intake Department. This signature flow and planning process is the PLURSING™ Method or PLANNING for NURSING, and its core strategies are embedded into The Nursing Narrative Note™ Formula, as well as The Nursing Narrative Note™ Blueprint. I will also be breaking down and providing additional clarity about this entire method during my live sessions in The Productive Home Health Nurse private group that you can join by clicking the button below. 

PLURSING Method for completing effective OASIS assessments.
The PLURSING Method for OASIS + Home Health Nurses.

The PLURSING™ Method is a cyclical view with a smaller continuous improvement cycle embedded in the entire OASIS assessment and documentation process, and it shows us the Privilege Points that our patients and their documentation are exposed to with you as their primary care provider and home health nurse.

A Privilege Point (as I’ve named them) is every interaction a patient and their OASIS documentation has with you as their home health nurse completing their assessments, advocating for them (verbally or written), or completing and submitting OASIS documentation on their behalf.

This is important because it helps us see the pathway that your patients’ documentation takes in order to get them the proper home health care they need.

This is demonstrated when one of your patient’s start of care (SOC) assessment isn’t completed within the mandatory 48-hour window, or they aren’t set-up with the proper disciplines (PT, MSW, etc.) that were prescribed. You now have a framework to look back on to see exactly where the communication broke down or where someone just completely dropped the ball.

The purpose of the PLURSING™ Method is to provide a framework that implements accountability and continuous improvement of your processes, and the accuracy of home health care services being provided to your patients.

If you improve the level of efficiency applied at each of these Privilege Points, you’ll not only upgrade your OASIS documentation skills and confidence, but also cultivate amazing relationships and rapport based on your capability, proficiency, and expertise with your patients as well as your agency.

Now that we have the OASIS process drilled down, let’s move on to the 4 things killing your OASIS assessment!


Maybe your previous agency wrote this in for you…

Or maybe you didn’t realize that you have to explicitly write out…

“Consent for care was obtained”.

I’ve come across both of the above reasons for nurses not including patient consent confirmation.

So, what happens when you don’t include this?

You already know (as I give your OASIS reviewers a side-eye)…

Your OASIS assessment submission will be returned during a time when you already have so much on your plate!

So to avoid this, all you need to do is have a standing document template for writing your OASIS nursing narratives that can be copied + pasted to your agency OASIS submission software.

At the very beginning of your template, you should place…

“Consent for care was obtained”.

Don’t have an OASIS nursing narrative template or just don’t have the time to put one together…no biggie, I got you covered!

You can download my free OASIS Nursing Narrative Note™ Formula below.

In the Nursing Narrative Note™ Formula, I share the items that Medicare requires home health nurses to include in every OASIS nursing narrative note, along with exactly where to place them so your submission can be approved the first time around!


I know it’s a basic concept, that obviously if you’re writing an OASIS nursing narrative note that you’ve fulfilled everything needed to ensure that your patient qualifies for home health care. 

BUT, that’s not always the case because not all home health nurses are clued in to the actual requirements of what I call the “Medicare Language” or the Medicare home health requirements.

Meaning, whenever you are communicating with Medicare you MUST write as if you are just meeting them and they have NO clue about your credentials, intentions, or actions (completed or to be carried out) as it pertains to the patient at hand.

And to be honest, each time you submit documentation to Medicare on behalf of your patients, it is a clean slate type of situation, and they are meeting that patient for the first time in whatever capacity or situation you are presenting at that very moment because…

Your assessment and documentation of your patient should always be changing or varying to some degree as they move through their health care journey to reach their individualized, realistic, optimal health care outcomes.

So, the easiest way to include your patients’ face-to-face encounter, is to just write…

“Face to Face Encounter: (Date of F2F encounter here)

And we’re done…plain and simple…right!


I call this item the “appetizer” 1) because I’m a true “phat (plat-in-hand-at-table girl” at heart (an amazing smelling meal can make any day my BEST DAY EVEEERRRR!!), and 2) because it’s the ABSOLUTE step that MUST happen before each of your OASIS assessments.

In fact, it determines if you should even move forward with completing a patient’s OASIS SOC assessment.

This appetizer is your patient’s proof of “Homebound” Status.

And almost INSTANTLY when you don’t provide proof of your patient being homebound…

Medicare DECLINES your submission!!!!!!!!!

To be frank, when this item is missing there is no need for the reviewer to read any further…period!

Because this is one of the MAIN determining factors of Medicare reimbursing your agency for the home health care you’ve provided to the patient thus far.

So, to ensure that everyone gets their “bags” or money, you can provide proof of your patients’ homebound status by first knowing what homebound status means and how to prove it.

Ultimately, your patient must meet Medicare’s requirements for “homebound” status, and to make this step easy for you, I’ve created a checklist below that presents the Medicare requirements for “homebound” status in a very simple and “plain English” way.

If you can check off the above requirements for each of your patients, then they are “homebound” and as long as your remaining OASIS documentation is up to par…Medicare should recognize your patient as qualified for home health care and reimburse your agency accordingly.


Wait a minute??!!

Doesn’t the mere fact that you’re even involved with this patient as a “nurse” justify their “skilled need”?

Because by definition you are a “Skilled care provider”

If I’m not mistaken…which for the record, I’m NOT?

Nope, that’s not the case at all (side-eye to Medicare)!

Reiterating that “whenever you are communicating with Medicare you MUST write as if you are just meeting them and they have NO clue about your credentials, intentions, or actions (completed or to be carried out) as it pertains to the patient”.

Meaning you need to provide proof that your patients’ diagnoses warrant the “skilled care” from you as a home health nurse.

The “care” that your patient requires can’t be “care” that is included in the work scope or license description of let’s say, a home health aide, that an aide could carry out legally, safely, and as frequently as your patient requires it.

You can decide on your patients’ ”skilled need” status by determining if they meet the requirements below.

If your patient meets the above requirements…you’re all set to move them through your OASIS assessment process!


Just by making these 4 simple changes to your OASIS nursing narrative notes, you will start to see a decrease in your OASIS resubmission rates.

However, writing your OASIS nursing narrative notes effectively is only a part of creating an effective OASIS assessment process.

You’ll still need to…

  • know and understand the foundations of home health from the nurses’ perspective to protect yourself,
  • get organized to handle long, complicated days without wasting time,
  • build a toolbox full of resources that you can pull from to make assessments and documentation faster and smoother, and
  • you MUST WANT to be a home health nurse!

Nursing in itself is very demanding and hard, so imagine not having back-up at the push of a button (or just down the hall for that matter) and having to brave the traffic to get from one patient to the next…

And oh yeah, that beautiful car that you love so much is going to take a beating!!

So you HAVE to LOVE what you do, and to be honest…it takes time for some to push through the hardships of home health nursing to get to the actual BENEFITS, and that’s okay too!

Our decisions aren’t always set in stone. So while at one point you might abhor home health nursing and LEAVE, by the next month you may love it and want to RETURN…and guess what???!!!

That’s okay too because I’ll be here along with ALL of the rest of my home health nurse tribe to welcome you back with open arms (heart hug to you…with a wink!)

For a better understanding of the foundations of home health nursing, and organization, join my Productive Home Health Nurse private group below.

To start building your toolbox of resources to pull from to make OASIS assessments and documentation faster, smoother, and safer for you… download my free Nursing Narrative Note™ Formula below.

I know this can all feel overwhelming, so just “Wu-saa” (while picturing Martin in Bad Boys II), and make your way down to your next steps that are laid out in a more digestible and bit-sized manner.


  1. If you think your OASIS assessment strategy could use some work, sign-up for my free OASIS Follow-Up Assessment Cheat Sheet™.
  2. If you don’t have an OASIS nursing narrative template yet, you can download my OASIS Nursing Narrative Note™Formula where I share the required items needed to have Medicare approve your submissions, along with where to place them.
  3. If you’d like additional OASIS nursing narrative note help with copy + paste answers for each of the required items including nursing assessment items with matching interventions based on your patient’s ICD code or nursing diagnosis without having to wreck your brain. You can join my Nursing Narrative Note™ Blueprint. That gives you all of my tried and true, already approved by Medicare swipeable OASIS nursing narrative note assessments and interventions.
  4. If you’d like to have an OASIS + Home Health Nursing mentor or support group at your fingertips, join my private group The Productive Home Health Nurse.
  5. If you’d to have your OASIS + Nursing Narrative Note reviewed and edited, apply for our OASIS + Nursing Narrative Note Audit™.
  6. Or, if you have completely full “to do “ list like most nurses and would like to have your nursing narrative note written for you, apply for our Custom Nursing Narrative Note.

I’ve thrown a lot at you during this post, and I’m sure you need to re-read and digest. So, take the time to digest it and put the pieces that you can use to work as you see fit!

Please feel free to comment below, and I’ll be back next week with more input and tips.  I hope to see you then 🙂 !

Remember, we are doing this on our terms, in our way, with  NO obligations to ANY one at the end of the day!

To your success, until next time, friends 🙂 !

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