OASIS Documentation Samples

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Reason(s) for Admission to Home Health

  • Degenerative Disc Disease
  • Lumbar Fusion
  • Back Precautions

Patient is a 71-year-old female patient with history of degenerative disc disease involving the lumbar spine and underwent lumbar fusion in June 2011. Between last year and this year had about 10 eye surgeries for cataract and glaucoma. Last surgery was on 06/18/2011 and is still in process of healing. Still reports some headaches. Patient will be seen by the PCP Dr. A in 2 weeks. Patient sees her once every 3 months. Patient reports his back and BLE are weak and he is prone for fall. None reported in recent times though. Patient also reports radiating nerve pain in BLE and spasms in his back limiting his ROM and activity. Patient is in need of continuing home health service due to his continuing needs for pain management and ADL training, and continued instructions on compliance with the HEP established by the therapist. Pain management has improved from the last certification period, as he reports. Patient currently reports pain between 2 and 6 on a scale of 0 – 10. Patient is continuing on Norco for now. Spasms in the back are better managed in recent times with Methocarbamol. Patient needs continued follow-up on this. Bilateral breath sounds in the bases are diminished. Patient reports pain in the back limiting his breathing effort. No adventitious breath sounds noted. No cough noted. Patient is dyspneic on moderate exertion. Patient was instructed on the need for deep breathing to avoid development of atelectasis in the lungs with collapse. Patient was also instructed on deep breathing and relaxation technique to help the pain status too. Heart sounds were regular. History of hypertension is positive and patient is being managed on a combination of Amlodipine, Valsartan, and HCTZ for management. Patient has history of hyperlipidemia and is being managed on statins. Patient has one episode of cardiac catheterization in 2002 for a 70% block. No MI reported. Systolic blood pressure over the certification period varied between 127 – 154. Diastolic varied between 71 – 87. Heart rate varied between 78 – 88.



Reason(s) for Admission to Home Health

  • Fall and Subsequent Hospitalization
  • Rehab
  • Foot Wound

Patient had a fall 2 months ago. Patient was taken to XXX hospital. The left foot was injured in the fall. Patient was diagnosed with poor circulation with neuropathy in both feet. Patient was moved to YYY Rehab for 5 weeks after stabilization at XXX. Patient did not like YYY and the care being given. Patient’s blood pressure and blood sugars were fluctuating a lot during this period. Patient was deteriorating, as caregiver reports. Upon his PCP, Dr. A’s recommendation, patient was pulled out from rehab and taken to Dr. A (PCP and geriatrics) at XXX again. Patient was discharged from XXX Hospital after stabilization to the ZZZ Nursing Home. Timeline of this transfers from one facility to the other is not clear with both patient and caregiver. Patient was discharged from ZZZ Nursing Facility yesterday. Patient has a wound on the left heel. Poor circulation and neuropathy happened to be detrimental factors for wound healing. Patient was tried 2 stents in the left foot to promote circulation. Patient was also started on nitroglycerin patches 0.4 mg/hour one patch every day on the left foot to bring vasodilation and promote circulation in the limb. Patient was also recommended hyperbaric therapy during the hospital stay. But, patient tolerated it poorly. So, he was discontinued on it. Patient has history of some autoimmune blood disorder. Both patient and caregiver are not sure of what it is. Patient has history of splenectomy. Patient will have blood transfusion frequently. Patient had his last transfusion of 2 units, a week ago. Patient is also started on Epogen, which he has not picked up yet from pharmacy. He reports that his son is picking it up today. Patient has history of Meniere’s disease in the inner ear of the right with poor balance issues.


Reason(s) for Home Health Admission

  • Hysterectomy
  • Bladder Lift

Patient is a 44-year-old female who had undergone partial hysterectomy on 08/20/2011 at XXX. Patient underwent a bladder lift during the procedure. Patient came home on 08/22/2011 and started to develop fever and chills. Patient went into the hospital on 08/26/2011. Upon evaluation, patient was found to have a kink in the right ureter with retrograde urine flow that resulted in pyelonephritis. Patient was diagnosed with an abscess in the right kidney and a drain was placed on 08/26/2011. Drain was removed on 08/28/2011. Patient was started on oral antibiotics on 08/28/2011 and was on them for two days. Today, PICC line was fixed on the right arm and patient was sent home with IV antibiotics. Patient has an indwelling urinary catheter fixed on 08/28/2011. Catheter noted to be in place and draining well. 200 ml of urine noted in the bag. Bag was emptied 2 hours ago, before she left the hospital. The color of the urine was noted to be WNL, light yellow colored. No sediment noted in the bag. Patient reported urgency and dysuria until yesterday, but reports improvement today. Patient reports mild diarrhea from the antibiotics she is on and her doctor is aware of it. No signs of gross dehydration noted though. Patient was instructed to keep herself hydrated by having liberal amounts of water intake.