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Audit Details and SOC Timing

Start of care date documented critical (required)

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 critical (required)

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.

Yes No N/A

Assessment completed by qualified clinician critical (required)

The assessment was completed by an appropriately qualified clinician per agency policy and home health requirements.

Yes No N/A

Functional Status Documentation

Mobility status documented critical (required)

Ambulation, transfers, and mobility limitations are documented with observable detail.

Yes No N/A

Self-care and ADL status documented critical (required)

Bathing, dressing, toileting, feeding, and other relevant ADL performance are documented.

Yes No N/A

Cognitive and communication status documented

Cognition, orientation, memory, and communication abilities or deficits are documented when applicable.

Yes No N/A

Functional limitations support skilled need critical (required)

Documented functional deficits support the need for home health services and are consistent with the plan of care.

Yes No N/A

Diagnoses and Clinical Accuracy

Primary diagnosis documented critical (required)

The primary diagnosis is clearly identified and consistent across the assessment and plan of care.

Yes No N/A

Secondary diagnoses and comorbidities documented when applicable

Relevant secondary diagnoses, comorbidities, or complicating conditions are documented when present.

Yes No N/A

Diagnosis documentation supports home health services critical (required)

The documented diagnoses support the need for skilled home health services and are not internally inconsistent.

Yes No N/A

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.

Yes No N/A

Homebound Status and Justification

Homebound status documented critical (required)

The record explicitly states whether the patient is homebound.

Yes No N/A

Clinical reasons for homebound status documented critical (required)

The record includes specific clinical reasons the patient has difficulty leaving home, such as weakness, pain, dyspnea, fall risk, or need for assistance.

Yes No N/A

Absences from home are described as infrequent or for medically necessary reasons critical (required)

The documentation supports that leaving home is infrequent, taxing, or limited to medically necessary absences when applicable.

Yes No N/A

Homebound justification is consistent with functional findings critical (required)

The homebound narrative aligns with the documented functional status, diagnoses, and care needs.

Yes No N/A

Documentation Completeness and Final Review

Assessment is internally consistent critical (required)

Dates, diagnoses, functional findings, and homebound statements do not conflict across the record.

Yes No N/A

Required assessment elements are complete critical (required)

No required SOC assessment elements are missing from the chart review.

Yes No N/A

Deficiencies documented with corrective action

Any deficiency or non-conformance is clearly documented with follow-up or corrective action noted.

Yes No N/A

Audit reviewer comments entered

Summarize key findings, deficiencies, and any follow-up needed.

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Run: OASIS Start of Care Assessment Documentation Audit

Audit Details and SOC Timing

Functional Status Documentation

Diagnoses and Clinical Accuracy

Homebound Status and Justification

Documentation Completeness and Final Review

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