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OASIS-D Part 3: Patient Tracking Information and Care Management

presented by Diana 'Dee' Kornetti and Cindy Krafft

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Disclosure Statement:


Financial: Dee Kornetti and Cindy Krafft are co-owners of the consulting business, Kornetti & Krafft Health Care Solutions. They receive compensation from MedBridge for this course.

Dee Kornetti is a chapter contributor to the  Handbook of Home Health Care Administration, 6th edition, and co-author of the book, The Post-Acute Care Guide to Maintenance Therapy, for which she receives compensation.

Cindy Krafft has written two books—The How-to Guide to Therapy Documentation and An Interdisciplinary Approach to Home Care and co-authored her third, The Post-Acute Care Guide to Maintenance Therapy, for which she receives compensation.

Nonfinancial: Dee Kornetti is the president of the Home Health Section of the APTA. Additionally, Dee Kornetti serves as the president of the Association of Homecare Coding and Compliance, and is a member of the Association of Home Care Coders Advisory Board and Panel of Experts.

Cindy Krafft has been involved at the senior leadership level of the Home Health Section of the American Physical Therapy Association. She has worked with CMS to clarify regulatory expectations and address proposed payment methodologies.

Satisfactory completion requirements: All disciplines must complete learning assessments to be awarded credit, no minimum score required unless otherwise specified within the course.

MedBridge is committed to accessibility for all of our subscribers. If you are in need of a disability-related accommodation, please contact support@medbridgeed.com. We will process requests for reasonable accommodation and will provide reasonable accommodations where appropriate, in a prompt and efficient manner.

Accreditation Check:
Patient assessment begins by gathering both demographic and clinical details that set the stage for understanding what needs to be done going forward. Although some of this information may be provided as part of the referral to home health, the clinician must confirm that it is current and accurate. This course will address both the collection of patient-specific information and how assessments connect to care planning items in the OASIS tool. It will also cover how the OASIS assessment informs care planning.

Meet Your Instructors

Diana 'Dee' Kornetti, PT, MA, HCS-D, HCS-C

Diana 'Dee' Kornetti, a physical therapist for 30 years, is a past administrator and co-owner of a Medicare-certified home health agency. Dee now provides training and education to home health industry providers through a consulting business, Kornetti & Krafft Health Care Solutions. She serves as chief operations officer with her business partners Cindy Krafft and…

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Cindy Krafft, PT, MS, HCS-O

Cindy Krafft brings more than 20 years of home health expertise that ranges from direct patient care to operational and management issues. Years spent in the homes of patients confirmed that she was in the best setting to focus on functionality and the specific challenges faced by each patient. Cindy recognizes that providing care in…

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Chapters & Learning Objectives

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1. OASIS Assessment: Gathering Patient Tracking and Past History Information 

Information provided as part of the referral process must be reviewed and confirmed with the patient in order to ensure accuracy. Missing details may need further investigation but cannot be overlooked. This chapter includes information on the following data items:
• M0010–M0060: Patient Tracking Sheet
• M0063–M0140: Patient Tracking Sheet
• M0150: Current Payment Sources
• M0080–M0090: Completing Assessment
• M0100: Reason Completed
• M0102/M0104: Initiation of Care
• M0110: Episode Timing
• GG0100: Prior Functioning: Everyday Activities
• GG0110: Prior Device Use
• M1041/M1046: Influenza Vaccine
• M1051/M1056: Pneumococcal Vaccine

2. OASIS Assessment: Care Management 

Careful consideration of patient-specific issues is critical to care planning. The OASIS contains several items that require the clinician to use his or her professional judgment to determine what may impact the course of care. This chapter includes information on the following data items:
• M1033: Risk for Hospitalization
• M1100: Patient Living Situation
• M2102: Types and Sources of Assistance
• M2200: Therapy Need

More Courses in this Series

OASIS-D Part 1: Introduction to Key Concepts

Presented by Diana 'Dee' Kornetti, PT, MA, HCS-D, HCS-C and Cindy Krafft, PT, MS, HCS-O

OASIS-D Part 1: Introduction to Key Concepts

Subscribe now, and access clinical education and patient education—anytime, anywhere—with video instruction from recognized industry experts.
Clinicians are often involved with OASIS data collection without a clear understanding of why the information is so important and what it is used for. In order to collect accurate data, clinicians must have a working knowledge of key concepts and terminology unique to the OASIS tool. This course will provide an overview of how OASIS data collection impacts both patient care and agency performance.

View full course details

OASIS-D Part 2: ICD-10 Coding

Presented by Diana 'Dee' Kornetti, PT, MA, HCS-D, HCS-C and Cindy Krafft, PT, MS, HCS-O

OASIS-D Part 2: ICD-10 Coding

Subscribe now, and access clinical education and patient education—anytime, anywhere—with video instruction from recognized industry experts.
Integral to agency compliance are the frontline clinicians who have primary responsibility for documenting the information required to support coding choices. Improved understanding of the guidelines, conventions, and documentation requirements by frontline personnel will not only help agency coders to efficiently complete OASIS coding tasks but will facilitate the timely submission of the agency's OASIS data for payment.

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OASIS-D Part 4: System-by-System Approach to Assessment

Presented by Diana 'Dee' Kornetti, PT, MA, HCS-D, HCS-C and Cindy Krafft, PT, MS, HCS-O

OASIS-D Part 4: System-by-System Approach to Assessment

Subscribe now, and access clinical education and patient education—anytime, anywhere—with video instruction from recognized industry experts.
In order for an assessment to be considered complete, the clinician must collect accurate OASIS data and provide patient-specific detail in the documentation. The course will focus on items specific to sensory status, respiratory status, and elimination.

View full course details

OASIS-D Part 5: Integumentary Assessment

Presented by Diana 'Dee' Kornetti, PT, MA, HCS-D, HCS-C and Cindy Krafft, PT, MS, HCS-O

OASIS-D Part 5: Integumentary Assessment

Subscribe now, and access clinical education and patient education—anytime, anywhere—with video instruction from recognized industry experts.
The OASIS contains items that are grouped similarly to items in a system-by-system patient assessment. It is vital to keep in mind that these items are designed to collect data and are not necessarily following clinician logic. This course will address the integumentary assessment and will cover how the collection of the OASIS data informs care team members in coordinating an integrated care plan.

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OASIS-D Part 6: Neuro-Emotional-Behavioral Assessment and Addressing Medications

Presented by Diana 'Dee' Kornetti, PT, MA, HCS-D, HCS-C and Cindy Krafft, PT, MS, HCS-O

OASIS-D Part 6: Neuro-Emotional-Behavioral Assessment and Addressing Medications

Subscribe now, and access clinical education and patient education—anytime, anywhere—with video instruction from recognized industry experts.
The OASIS contains items that are grouped similarly to items in a system-by-system patient assessment. It is vital to keep in mind that these items are designed to collect data and are not necessarily following clinician logic. This course will address both the neuro-emotional-behavioral status and the management of medications. This course covers how the collection of the OASIS data informs care team members and facilitates an integrated care plan.

View full course details

OASIS-D Part 7: Functional Assessment and Fall Risk

Presented by Diana 'Dee' Kornetti, PT, MA, HCS-D, HCS-C and Cindy Krafft, PT, MS, HCS-O

OASIS-D Part 7: Functional Assessment and Fall Risk

Subscribe now, and access clinical education and patient education—anytime, anywhere—with video instruction from recognized industry experts.
The OASIS contains items that are grouped, similar to a system-by-system patient assessment. It is vital to keep in mind that these items are designed to collect data and are not necessarily following clinician logic. In order for an assessment to be considered accurate, the clinician must have a clear understanding of the logic behind OASIS items specific to function. This course will set the stage for determining “safe and able." This course also covers how the collection of the OASIS data informs care team members in coordinating an integrated care plan.

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OASIS-D Part 8: Self-Care Assessment

Presented by Diana 'Dee' Kornetti, PT, MA, HCS-D, HCS-C and Cindy Krafft, PT, MS, HCS-O

OASIS-D Part 8: Self-Care Assessment

Subscribe now, and access clinical education and patient education—anytime, anywhere—with video instruction from recognized industry experts.
The OASIS contains items that are grouped in a similar way to items in a system-by-system patient assessment. It is vital to keep in mind that these items are designed to collect data and are not necessarily following clinician logic. This course will address the assessment of self-care, using both the “M” and “GG” versions of OASIS items.

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OASIS-D Part 9: Mobility Assessment

Presented by Diana 'Dee' Kornetti, PT, MA, HCS-D, HCS-C and Cindy Krafft, PT, MS, HCS-O

OASIS-D Part 9: Mobility Assessment

Subscribe now, and access clinical education and patient education—anytime, anywhere—with video instruction from recognized industry experts.
The OASIS contains items that are grouped in a similar way to items in a system-by-system patient assessment. It is vital to keep in mind that these items are designed to collect data and are not necessarily following clinician logic. This course will address the assessment of mobility, using both the “M” and “GG” versions of OASIS items.

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OASIS-D Part 10: Discharge- and Transfer-Specific Items

Presented by Diana 'Dee' Kornetti, PT, MA, HCS-D, HCS-C and Cindy Krafft, PT, MS, HCS-O

OASIS-D Part 10: Discharge- and Transfer-Specific Items

Subscribe now, and access clinical education and patient education—anytime, anywhere—with video instruction from recognized industry experts.
The accurate completion of a discharge or transfer OASIS is as important as all the other time points. There are specific items that must be thoroughly understood by the clinician to ensure that data is collected consistently and that the additional clinical content provided best represents each individual patient. This course covers how completion of the OASIS assessment contributes to coordinating an integrated discharge plan.

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