OASIS Start of Care Assessment Documentation Audit

Inspection template for verifying timely completion and documentation quality of the OASIS-E2 Start of Care comprehensive assessment, including functional status, diagnoses, and homebound justification.

Audit Details and SOC Timing

• Start of care date documented
  SOC date is clearly documented in the record and matches the episode start date.
• M0090 date completed no later than 5 calendar days after SOC
  The comprehensive assessment completion date is within 5 calendar days of the start of care date per 42 CFR 484.55(b)(1).
• Assessment completion date matches documented M0090
  The date in the chart aligns with the M0090 completion date and no conflicting dates are present.
• Assessment completed by qualified clinician
  The assessment was completed by an appropriately qualified clinician per agency policy and home health requirements.

Functional Status Documentation

• Mobility status documented
  Ambulation, transfers, and mobility limitations are documented with observable detail.
• Self-care and ADL status documented
  Bathing, dressing, toileting, feeding, and other relevant ADL performance are documented.
• Cognitive and communication status documented
  Cognition, orientation, memory, and communication abilities or deficits are documented when applicable.
• Functional limitations support skilled need
  Documented functional deficits support the need for home health services and are consistent with the plan of care.

Diagnoses and Clinical Accuracy

• Primary diagnosis documented
  The primary diagnosis is clearly identified and consistent across the assessment and plan of care.
• Secondary diagnoses and comorbidities documented when applicable
  Relevant secondary diagnoses, comorbidities, or complicating conditions are documented when present.
• Diagnosis documentation supports home health services
  The documented diagnoses support the need for skilled home health services and are not internally inconsistent.
• Medication or treatment factors affecting assessment documented
  Relevant clinical factors that affect the assessment, such as therapy, wound care, or medication management, are documented when applicable.

Homebound Status and Justification

• Homebound status documented
  The record explicitly states whether the patient is homebound.
• Clinical reasons for homebound status documented
  The record includes specific clinical reasons the patient has difficulty leaving home, such as weakness, pain, dyspnea, fall risk, or need for assistance.
• Absences from home are described as infrequent or for medically necessary reasons
  The documentation supports that leaving home is infrequent, taxing, or limited to medically necessary absences when applicable.
• Homebound justification is consistent with functional findings
  The homebound narrative aligns with the documented functional status, diagnoses, and care needs.

Documentation Completeness and Final Review

• Assessment is internally consistent
  Dates, diagnoses, functional findings, and homebound statements do not conflict across the record.
• Required assessment elements are complete
  No required SOC assessment elements are missing from the chart review.
• Deficiencies documented with corrective action
  Any deficiency or non-conformance is clearly documented with follow-up or corrective action noted.
• Audit reviewer comments entered
  Summarize key findings, deficiencies, and any follow-up needed.