Why Your OASIS Assessment Nursing Note Sucks and How to Write Them Better | rnventingnursing.com

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Why Your OASIS Assessment Nursing Note Sucks and How to Write Them Better

OASIS nursing note…

Have you been putting off  “getting to know” your OASIS nursing notes for the longest time?

You thought you could ask your manager about it quickly but you underestimated the time it would take for them to “get-back” to you. 

Or maybe you’ve already tried “Frankensteining” (a Chanaism :)!) it but you’re extremely lost. You know you’re missing a few critical pieces and you’re just plain unhappy with all of the resubmissions you’ve been having to complete.

What was supposed to be a normal, easily manipulated part of your OASIS documentation is now sucking the life and time out of your days. It’s exhausting, depressing and discouraging. You’re not even sure if it’s worth all of the effort.

When you start writing your OASIS nursing narrative note, it’s hard to decide what’s important and what’s not.

It’s difficult to stay focused. There are so many words that you need to include and learn, and all those shiny objects (anything else that seems even remotely more interesting).

I know exactly how that feels!

It took me 2 long months to get an understanding of the OASIS nursing note and another 2 weeks or so before I figured out how to speak the “Medicare language”.

A lot of that initial stalling was because I didn’t have a plan for how I wanted to approach learning about the OASIS nursing note. I didn’t know what would be or how much of it was going to be enough to get me started off on the correct “effective OASIS documentation” track.

“Getting to know”  the OASIS nursing note is great, but without a plan in place for understanding, organizing, and crafting it, the entire goal will be a “hot mess”!

A lot of what goes into writing your OASIS nursing note that speaks to Medicare and gets you paid is the FOUNDATION and road map.

And this FOUNDATION or PLAN that you need to have in place to write your OASIS nursing notes effectively is EXACTLY what we’re going to jump into!

In order for your FOUNDATION or PLAN to be successful, it MUST help you:

  • understand, organize, and craft your OASIS nursing narrative note. 

And when these three are included in your PLAN, the process of writing this “extremely important” note offers so much fundamental and continuous knowledge that places your goals as well as those of your patients…right at your fingertips! 

To jump right in…

In this post, we’ll discuss:

  • OASIS nursing note knowledge and how it works
  • How to organize your OASIS nursing note, and 
  • How to use your OASIS nursing note to guide your OASIS assessments.
OASIS nursing note guide

So, how does this all tie into your OASIS nursing narrative notes level of “suckification” (haha, another Chanaism)…you ask?

In short, when you aren’t trained on EXACTLY what needs to be included in or in what order…we tend to just throw things together while hoping and praying that something sticks or looks acceptable enough to Medicare for them to press the “APPROVED” button.

However, that’s NEVER a good plan or approach, especially when you are already short on time and knowledge.

In fact, having a plan that will guide you through understanding, organizing, and crafting your OASIS nursing note is EXACTLY what this moment calls for…

And guess what…I’m gonna give YOU that EXACT PLAN!

Let’s get into it…shall we :)!

What Is OASIS Nursing Note Knowledge And How Does It Work

OASIS nursing note knowledge is understanding how each patient’s OASIS assessment data translates into a nursing narrative that signifies to Medicare that you as the home health nurse and primary care provider in the home… 

  • knows the Medicare home health care eligibility requirements, (you can read more about this here),
  • have verified that your patient qualifies for each and provided proof per their definitions (you can read more about this here),
  • have completed a comprehensive assessment (be it start of care or follow-up, etc…you can download a F/U visit cheat sheet here),
  • collected assessment data to initiate or continue each patient’s home health care documentation trail to positive health care outcomes, and
  • is aware that Medicare uses the OASIS nursing note for such and therefore manages that area/note to the advantage of fulfilling the healthcare needs of the patient.

Every home health nurse needs to know the fundamentals of the OASIS nursing note.

Because the OASIS nursing note is a large part of each patient’s OASIS assessment and it holds close to 83% of your patient’s assessment data. 

Therefore, not properly writing or attempting to skip this portion means preventing Medicare approval, and depriving your patients of life-saving health care. 

Which also means adding on to your already lengthy OASIS documentation time with more resubmissions.

Writing your OASIS nursing note might seem overwhelming and difficult, but it doesn’t have to be.

Crafting your OASIS nursing notes can be easy when you take the time to learn or understand them, collect your OASIS assessment data strategically, and organize your patient OASIS assessment.

How To Organize Your OASIS Nursing Note

In home health, OASIS is the MAIN currency.

We complete OASIS assessments and we submit OASIS documentation.

When submitting your OASIS documentation it’s important to use Medicare’s Language, and using their language pertains to your entire submission as a whole, but more specifically to your nursing note.

Your OASIS nursing note should be organized as displayed below.

Formula for OASIS nursing note
The PLURSING™ Method’s: Nursing Narrative RefeRNce™ Formula

After you have the organization down, you can then use the given “Medicare Language” found below to fill-in your OASIS nursing note.

Medicare language for OASIS nursing note
The PLURSING™ Method’s: “Medicare Language”

You can find the specifics for speaking the “Medicare Language” in the Nursing Narrative Note Blueprint along with “copy + paste” nursing assessment and intervention options.

How To Use Your OASIS Nursing Note To Guide Your OASIS Assessments.

Now the question is…how can I use this to guide my OASIS assessments?

I gotcha covered!

Once you know EXACTLY what’s needed to write your OASIS nursing note, you can use those specific items to guide your OASIS assessments. For instance, we know that before you even touch your patient they need to agree to receive home health care, sign their contract, and meet Medicare’s eligibility requirements.

Which means, that your SOC assessments should ALWAYS follow the same flow of (or a variation of):

  1. Introducing yourself to the patient,
  2. Getting them familiar with home health and why it was prescribed for them and by whom, and
  3. Asking the questions you need to be answered in order to verify their Medicare eligibility.

Keeping in mind that you may not need to ask the questions in #3 if your observations upon entering their home have already provided verification. Now let’s check out, why your OASIS nursing note suck :)!

Your OASIS nursing note “sucks” because you weren’t trained in ALL of this…which is def not your fault, but now that you do know and are aware of ALL of this…what are you going to do about it?

Get to know your OASIS nursing note…maybe ( as I shrug!?)?

It’s ALWAYS your choice…so, in case you’d like…

To get started with “getting to know” your OASIS nursing note (or with learning anything in particular that you will need to push your career advancement), you need to have a plan that includes teaching you the fundamentals and helps you understand, organize, and craft the nursing note.

YOUR ACTION ITEMS:

  1. Get started with crafting your “Medicare-Friendly” OASIS nursing note by downloading the Nursing Narrative Note™ Blueprint.
  2. Join the exclusive Productive Home Health Nurse group

Take some time and think about what I’ve shared, and please comment below or email me your questions.  Stay safe 🙂

Until next time my amazing friends 🙂  

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