Home Health Skilled Nursing OASIS Assessment Templates

This post provides home health skilled nursing OASIS assessment templates for writing OASIS assessment note for Start of Care and Recertification Evaluation in home healthcare setting. We have listed the reasons for patient’s admission assessment and based on those reasons we have built a summary which will explain and justify the need for admitting the patient to home healthcare services.

Home Health Skilled Nursing OASIS Assessment Templates-Start of Care

Template 1

Reason(s) for Home Health Admission

• DVT
• Coumadin
• INR lab

Patient had an episode of DVT on 09/19/2011, involving the left arm. The patient experienced an intense pain that was travelling up his arm and then, slowly got into the chest. Patient was taken to ER at XXX. Patient was started on Heparin drip initially. Patient was started on Coumadin later and gradually the heparin drip was discontinued. Coumadin dose is 5 mg per day currently. Labs to be drawn for PT/INR, as ordered. PT today is 14.1 and INR is 1.4.  Lab drawn on the right index finger. Patient was instructed that an ideal reading on INR for a patient taking Coumadin should be between 2 and 3. With the current result today, he is more likely to form clots, Patient was instructed to be moderate on greens in his diet.

Template 2

Reason(s) for Home Health Admission

• Recurrent UTIs
• BPH

Patient was taken to ER at XXX on 05/06/2011 with chills and rigors. Patient came home yesterday 05/09/2011. Patient was diagnosed with UTI. Patient was initially started on Zosyn and currently, he is taking Ciprofloxacin. BPH and urinary retention is suspected to be the inciting cause for the UTI. Patient is being scheduled for prostate workup on 05/12/2011. Patient is currently started on Tamsulosin for the BPH. Patient has been coming down with frequent UTIs in recent times.

Template 3

Reason(s) for Home Health Admission

• CHF
• CAD
• CABG
• Diabetes
• Stroke Affecting Swallowing
• Dysphagia
• G-tube Feedings

The +1 edema BLE evident. Caregiver was instructed to have the BLE elevated with a pillow to help return of fluid to circulation. Patient is positive for CHF. History of CAD and quadruple CABG +ve. No changes happened in recent times with regards to her cardiac medications. Systolic blood pressure has been elevated in recent times along with the heart rate. Caregiver takes care of the g-tube feedings and the dressing changes every day. Swallowing test gave permission for puree food. Caregiver gives one can of puree through the mouth every day. G-tube feedings are still the main source of nutrition. Tube placement was checked and was noted to be in place. Patient’s nutrition every day comprises of 3 cans of Nepro through the G-tube and 1 puree through the mouth. 64 ounces of fluid every day is the fluid limitation. Patient was seen by her gastroenterologist last month. The site of g-tube insertion was erythematous at the time of visit and mupirocin ointment was prescribed to be applied daily at the erythematous site and 4 x 4 gauze dressing around the g-tube site was discontinued. No 4 x 4 noted today at the site of insertion. The erythema was noted to have cleared. Patient’s blood sugars have been doing fine over the last 2 months with some fasting readings elevated. No medication changes happened in the last 6 months.

Home Health Skilled Nursing OASIS Assessment Templates-Recertification Evaluation

We have listed the reasons for patient’s recertification need and based on those reasons we have built a summary which will explain and justify the need for continuing the home healthcare services for the patient over the next certification period.

Template 4

Reason(s) for Home Health Recertification

• Development of Pressure Ulcer on the Back
• Exacerbation of Multiple Sclerosis with Increase of Incontinence
• Deterioration of Motor Strength
• Increasing Activity Intolerance

Patient is chair bound and has a moderate risk of pressure ulcer development. Caregiver helps turn the patient sides timely and helps prevent development of the pressure ulcers. Heart sounds regular. Patient’s systolic readings varied over 101 – 147. Diastolic readings varied between 61 – 89. Heart rate varied between 65 – 95. Patient is continuing on Lisinopril currently. No dosage changes were noted in the last 2 months. Dose of Atorvastatin changed though during this certification period. Patient’s incontinence with bowel and bladder has exacerbated secondary to the exacerbation of MS recently. Patient is on Oxybutynin for management of the bladder incontinence. Patient is prone for UTIs and so, is on prophylactic antibiotics for prevention if infections. Patient presented with some low grade fever during an office visit with his PCP, Dr. A, at XXX, on 10/11/2010. Urine sample was collected at XXX. The result came positive on 10/16/2010. Patient was prescribed antibiotic on 10/17/2010. Caregiver delayed picking the antibiotic up and the antibiotic course was started on 10/24/2010. Antibiotics to continue for 10 days. Nitro/mono/macro 100 twice daily. Patient reports the burning sensation has improved, but frequency is still present. Mild difficulty swallowing is positive. Patient needs assistance with feeding and caregiver helps with it. OT is working on improving independence with ability to feed self. Caregiver reports that she makes small chunks of solid food and patient will eat it slowly, when she feeds him. History of seizures from a MVA in 1997. No recent seizure activity reported. Patient feels a little down with him being dependent on his mother for ADL performance.

Template 5

Reason(s) for Home Health Recertification

• Current Episode of Acute Bronchitis
• On Antibiotics Currently
• Dry Cough Continues
• Decently Managed BP
• Exacerbation of Symptoms of Urinary Retention

Comprehensive patient was performed today on the patient by RN. Left base was noted to be diminished with shallow breath pattern. Expiratory wheeze was noted in bilateral apices. Patient presented with some productive cough in March and was seen by Dr. A, on 03/18/2011. Patient was prescribed Virtussin A/C syrup. The expectoration gradually subsided and currently, the cough is dry. Patient is continuing to take the syrup for now. Patient will probably see the doctor next week for follow-up, as caregiver observes. No appointment has been fixed yet. Patient has history of asthma and is on Montelukast Sodium for the same. Patient has history of prostatic cancer and prostatic hypertrophy with occasional symptoms of incomplete bladder emptying and urinary retention reported. Patient is currently continuing on Tamsulosin for the same. No recent PSA evaluation was conducted on the patient, as he reports. No episodes of UTI reported over the certification period. Occasional episodes of constipation with slowing of bowel movements reported by the caregiver. Patient takes Docusate for relief from constipation. Patient is mostly limited to wheelchair and bed and is totally dependent on toileting. Caregiver is very regular at cleaning him up after bowel movements to prevent risk for skin integrity. Patient is recertified today for certification period for unresolved cough, symptoms of prostatic hypertrophy, sleep disturbance and onset of clinical depression, asthma, and HTN for the certification period 04/03/2011 – 05/02/2011. Patient needs help with ADL/IADL performance and so, HHA assistance is being continued three times a week.

Template 6

Reason(s) for Home Health Recertification

• Exacerbation of Back Pain
• Degenerative Disc Disease
• Pain and Spasms Diffusely Limiting ROM
• HTN

Patient is a 52-year-old male living in Dallas with his family on the second floor of the building he lives in. Patient’s health history includes hypertension, 2 episodes of stroke involving the dominant side, cirrhosis of liver, degenerative disc disease involving the cervical and lumbar spine with consequent fusion surgeries on both the sites, and pain involving the back, muscle spasms from the stroke he had. Patient is on Norco and Fentanyl for the pain he complains. Patient is also on Carisoprodol for the spasms he has. Pain and spams limiting his ROM and activity are a major concern for the patient. Bilateral breath sounds were noted to be clear and vesicular. No cough noted. No episodes of respiratory distress reported in recent times. Heart sounds were noted to be regular. Patient has history of hypertension and is on Lisinopril and Nifedipine for management. Patient reports that he is not sure how his blood pressures usually do, as he does not take a reading every day. Patient reported that he has a machine. Patient had an episode of stroke about 4 months ago. Patient passed out and was taken to ER at Baylor Dallas. Patient reported that he was told that there is an evidence of another stroke too that he had in recent times on the MRI. No episodes of chest pain reported. Patient reports episodes of incontinence due to delay in reaching the restroom, as he is weak on his right side. Urine is reportedly clear and no UTIs reported in recent times. Occasional episodes of GERD reported, but patient is currently not on any medication for it. Constipation reported secondary to Norco. Patient is on Docusate for management and reports moderate relief. Patient has history of hepatitis and cirrhosis of liver. The etiology of hepatitis and cirrhosis are not clear, as patient is not sure if he had any viral infections. They could be of alcoholic origin, as caregiver observes. No changes with appetite in recent times reported. No dysphagia reported. Patient reports feeling low as he is unable to work anymore and expresses anxiety if he would ever be able to. Medications were reconciled with the patient and caregiver. Care plan was discussed. PT services was also discussed. Patient and caregiver verbalized understanding with the plan of care.

You can generate similar summary using our customizable home health skilled nursing OASIS assessment templates. Our home health skilled nursing OASIS assessment templates generate customized narratives for individual patient needs with few clicks. The narrative is generated once you click the Submit button at the end of the page. This summary could be copied and pasted into the comments section, if you use an EMR software, or copied and pasted onto an addendum sheet that you can attach to the OASIS form if you use paper documentation. This helps in making the documentation quicker and easier.

We offer customizable home health skilled nursing OASIS assessment templates for Start of Care, Resumption of Care, Recertification Evaluation, 60-Day Summary and Discharge.

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