SELECT *, patient.Last_Name_M0040 AS Last_Name, patient.First_Name_M0040 AS First_Name, patient.Middle_Initial_M0040 AS Middle FROM #Request.prefix_db_agency#.Assessment_New INNER JOIN #Request.prefix_db_agency#.patient ON (Assessment_New.Patient_ID=patient.Patient_ID) WHERE Assessment_New.Assessment_ID='#session.cs.AssessmentId#' select Last_Name, First_Name from #Request.prefix_db_lookup#.Employee where Employee_ID = '#DeathForm.Record_Created_By#' SELECT * FROM #Request.prefix_db_lookup#.Assessment_Questions_lookup JOIN #Request.prefix_db_lookup#.Assessment_Answer_lookup ON Assessment_Answer_lookup.question_id = Assessment_Questions_lookup.id WHERE Assessment_Answer_lookup.Deleted <> 1 AND Assessment_Questions_lookup.assessment_reason = '9 - Discharge from agency' AND Assessment_Questions_lookup.questions like 'GG0%' GROUP BY Assessment_Answer_lookup.answer_label ORDER BY Assessment_Questions_lookup.order_id ASC

Discharge From Agency OASIS Assessment	#DeathForm.Last_Name#, #DeathForm.First_Name# #DeathForm.Middle#

#DeathForm.First_Name_M0040# #DeathForm.Last_Name_M0040#
	SOC Date #DateFormat(DeathForm.Start_of_Care_M0030,"mm/dd/yyyy")#
	Certification #DateFormat(DeathForm.Certification_Start,"mm/dd/yyyy")# *to #DateFormat(DeathForm.Assessment_Completed_M0090,"mm/dd/yyyy")#*
9 - Discharge	Completed by #GetE.Last_Name# #GetE.First_Name#



CLINICAL RECORD ITEMS

(M0080) Discipline of Person Completing Assessment:	#DeathForm.Person_Complete_M0080#

(M0090) Date Assessment Completed:	#DateFormat(DeathForm.Assessment_Completed_M0090,"mm/dd/yyyy")#



PATIENT HISTORY AND DIAGNOSES

(M1040)(M1041) Influenza Vaccine: Did the patient receive the Influenza from your agency for this year's influenza season (October 1 through March 31) during this episode of care?	#DeathForm.M1040_Influ#

(M1045)(M1046) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:	#DeathForm.M1045_Influ#

(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination (for example, pneumovax)?	#DeathForm.M1050_Pneu#

(M1055)(M1056) Reason PPV not receieved: If patient did not receive the pneumoccal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:	#DeathForm.M1055_Pneu#



SENSORY STATUS

(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):	#DeathForm.Speech_M0410#

(M1242) Frequency of Pin Interfering with patient's activity or movement:	#DeathForm.Freq_of_Pain_M0420#



INTEGUMENTARY STATUS

(M1306) Does this patient have at least one Unhealed Pressure Ulcer at Stage II or Higher or designated as "unstageable"?	#DeathForm.M1306_Unhealed_Pressure#


Discharge Page 1

#DeathForm.First_Name_M0040# #DeathForm.Last_Name_M0040#

9 - Discharge

Completed

#DateFormat(DeathForm.Assessment_Completed_M0090,"mm/dd/yyyy")#

(M1307) The Oldest Non-epithelialized Stage II
Pressure Ulcer that is present at discharge

#DeathForm.M1307_Oldest#

(M1308)(M1311) Curent Number of Unhealed (non-epithelialized) Pressure Ulcer at Each Stage: (Enter "0"
if none; excludes Stage I pressure ulcers)

a. Stage II: Partial thickness loss of dermis	#DeathForm.M1308_a_12_Pressure#

b. Stage III: Full thickness tissue loss.	#DeathForm.M1308_b_12_Pressure#

c. Stage IV: Full thickness tissue loss	#DeathForm.M1308_c_12_Pressure#

d.1 Unstageble: Known or likely but unstageable due to non-removable dressing or device	#DeathForm.M1308_d_12_Pressure#

d.2 Unstageble: Known or likely but unstageable due to coverage of wound bed by slough and/or eschar	#DeathForm.M1308_d_22_Pressure#

d.3 Unstageble: Suspected deep tissue injury in evolution.	#DeathForm.M1308_d_32_Pressure#

(M1310) Pressure Ulcer Length: Longest length
"head-to-be" (cm)

#DeathForm.M1310_Length#

(M1312) Pressure Ulcer Width: Width of the
same pressure ulcer; greatest width
perpendicular to the length (cm)

#DeathForm.M1312_Width#

(M1314) Pressure Ulcer Depth: Depth of the
same pressure ulcer

#DeathForm.M1314_Depth#

(M1320) Status of Most Problematic
(Observable) Pressure Ulcer:

#DeathForm.Pressure_Ulcer_status_M0464#

(M1322) Current number of Stage I Pressure
Ulcers: Intact skin with non-blanchable redness
of a localized area usually over a bony
prominence.

#DeathForm.Pressure_Ulcer_a_M0450#

(M1324) Stage of Most Problematic Unhealed
(Observable) Pressure Ulcer:

#DeathForm.Pressure_Ulcer_stage_M0460#

(M1330) Does this patient have a Stasis Ulcer?

#DeathForm.Stasis_Ulcer_M0468#

(M1332) Current Number of (Observable) Stasis Ulcer(s)

#DeathForm.Stasis_Ulcer_Num_M0470#

(M1334) Stage of Most Problematic
(Observable) Stasis Ulcer:

#DeathForm.Stasis_Ulcer_status_M0476#

(M1340) Does this patient have a Surgical
Wound?

#DeathForm.Surgical_Wound_M0482#

(M1342) Status of Most Problematic
(Observable) Surgical Wound:

#DeathForm.Surgical_Wound_status_M0488#

(M1350) Does pr have a Skin Lesion or Open
Wound, excluding bowel ostomy, other than
those described above that is receiving
intervetion by the HHA?

#DeathForm.M1350_Other_Wounds#
Integumentary: Rash(es)

Discharge Page 2

#DeathForm.First_Name_M0040# #DeathForm.Last_Name_M0040#

9 - Discharge

Completed

#DateFormat(DeathForm.Assessment_Completed_M0090,"mm/dd/yyyy")#

RESPIRATORY STATUS

(M1400) When is the patient dyspneic or
noticeably Short of Breath?

#DeathForm.Breathing_M0490#

(M1410) Respiratory Treatments utilized at
home:

#DeathForm.Resp_Treatments_M0500#

(M1500) Symptoms in Heart Failure Patients: If
patient has been diagnosed with heart failure,
did the patient exhibit symptoms indicated by
clinical heart failure guidelines (including
dyspnea, orthopnea, edema, or weight gain) at
any point since the previous OASIS
assessment?

#DeathForm.M1500_Symptoms#

(M1510) Heart Failure Follow-up: If patient has
been diagnosed with heart failure and has
exhibited symptoms indicative of heart failure
since the previous OASIS assessment, what
action(s) has (have) been taken to respond?
(Mark all that apply.)

#DeathForm.M1510_Hrt_FU#

ELIMINATION STATUS

(M1600) Has this patient been treated for a
Urinary Tract Infection in the past 14 days?

#DeathForm.UTI_M0510#

(M1610) Urinary Incontinence or Urinary
Catheter Presence:

#DeathForm.Urinary_Incont_M0520#

(M1615) When does Urinary
Incontinence occur?

#DeathForm.Urinary_Incont_when_M0530#

(M1620) Bowel Incontinence Frequency:

#DeathForm.Bowel_Incont_M0540#

NEURO/EMOTIONAL/BEHAVIORAL STATUS

(M1700) Cognitive Functioning: Patient's current
(day of assessment) level of alertness,
orientation, comprehension, concentration, and
immediate memory for simple commands.

#DeathForm.Cog_Function_M0560#

(M1710) When Confused (Reported or Observed
Within the Last 14 Days):

#DeathForm.When_confused_M0570#

(M1720) When Anxious (Reported or Observed
Within the Last 14 Days):

#DeathForm.When_Anxious_M0580#

(M1740) Cognitive, behavioral, and psychiatric
symptoms that are demonstrated at least once a
week (Reported or Observed)

#DeathForm.Patient_Behav_weekly_M0610#

Discharge Page 3

#DeathForm.First_Name_M0040# #DeathForm.Last_Name_M0040#

9 - Discharge

Completed

#DateFormat(DeathForm.Assessment_Completed_M0090,"mm/dd/yyyy")#

(M1745) Frequency of Disruptive Behavior
Symptoms (Reported or Observed) Any physical,
verbal, or other disruptive/dangerous symptoms
that are injurious to self or others or jeopardize
personal safety.

#DeathForm.Patient_Behav_freq_M0620#

AD LOADLs

(M1800) Grooming: Current ability to tend safely
to personal hygiene needs (i.e., washing face and
hands, hair care, shaving or make up, teeth or
denture care, fingernail care).

#DeathForm.Grooming_M0640#

(M1810) Current Ability to Dress Upper Body
safely (with or without dressing aids) including
undergarments, pullovers, front-opening shirts
and blouses, managing zippers, buttons, and
snaps:

#DeathForm.Dress_Upper_M0650#

(M1820) Current Ability to Dress Lower Body
safely (with or without dressing aids) including
undergarments, slacks, socks or nylons, shoes:

#DeathForm.Dress_Lower_M0660#

(M1830) Bathing: Current ability to wash entire
body safely. Excludes grooming (washing face,
washing hands, and shampooing hair).

#DeathForm.Bathing_M0670#

(M1840) Toilet Transferring: Current ability to get
to and from the toilet or bedside commode safely
and transfer on and off toilet/commode.

#DeathForm.M1840_Toilet#

(M1845) Toileting Hygiene: Current ability to
maintain perineal hygiene safely, adjust clothes
and/or incontinence pads before and after using
toilet, commode, bedpan, urinal. If managing
ostomy, includes cleaning area around stoma.

#DeathForm.M1845_Toilet#

(M1850) Transferring: Current ability to move
safely from bed to chair, or ability to turn and
position self in bed if patient is bedfast.

#DeathForm.Transferring_M0690#

(M1860) Ambulation/Locomotion: Current ability
to walk safely, once in a standing position, or
use a wheelchair, once in a seated position, on a
variety of surfaces.

#DeathForm.Ambulation_M0700#

Discharge Page 4

#DeathForm.First_Name_M0040# #DeathForm.Last_Name_M0040#

9 - Discharge

Completed

#DateFormat(DeathForm.Assessment_Completed_M0090,"mm/dd/yyyy")#

(M1870) Feeding or Eating: Current ability to
feed self meals and snacks safely. Note: This
refers only to the process of eating, chewing,
and swallowing, not preparing the food to be
eaten.

#DeathForm.Eating_M0710#

(M1880) Current Ability to Plan and Prepare
Light Meals (e.g., cereal, sandwich) or reheat
delivered meals safely:

#DeathForm.Meal_Prep_M0720#

(M1890) Ability to Use Telephone: Current
ability to answer the phone safely, including
dialing numbers, and effectively using the
telephone to communicate.

#DeathForm.Use_Phone_M0770#

MEDICATIONS

(M2004) Medication Intervention: If there were any
clinically significant medication issues since the
previous OASIS assessment, was a physician or the
physician-designee contacted within one calendar
day of the assessment to resolve clinically
significant medication issues?

#DeathForm.M2004_Med_Int#

(M2015) Patient/Caregiver Drug Education
Intervention: Since the previous OASIS
assessment, was the patient/caregiver
instructed by agency staff or other health care
provider to monitor the effectiveness of drug
therapy, drug reactions, and side effects, and
how and when to report problems that may
occur?

#DeathForm.M2015_Drug_Edu#

(N12020) Management of Oral Medications:
Patient's current ability to prepare and take all oral
medications reliably and safely, including
administration of the correct dosage at the
appropriate times/intervals. Excludes injectable
and IV medications.

#DeathForm.Oral_Meds_M0780#

(M2030) Management of Injectable Medications:
Patient's current ability to prepare and take all
prescribed injectable medications reliably and
safely, including administration of correct dosage
at the appropriate times/intervals. Excludes IV.

#DeathForm.Inject_Meds_M0800#

CARE MANAGEMENT

(M2100)(M2102) Types and Sources of Assistance: Determine the level of caregiver ability and willingness
to provide assistance for the following activities, if assistance is needed.

a. ADL assistance; transfer/ ambulation, bathing	#DeathForm.M2100a_Equip#

b. IADL assistance (e.g., meals, housekeeping)	#DeathForm.M2100b_Equip#

Discharge Page 5

#DeathForm.First_Name_M0040# #DeathForm.Last_Name_M0040#

9 - Discharge

Completed

#DateFormat(DeathForm.Assessment_Completed_M0090,"mm/dd/yyyy")#

c. Medication administration	#DeathForm.M2100c_Equip#

d. Medical procedures/ treatments	#DeathForm.M2100d_Equip#

e. Management of Equipment	#DeathForm.M2100e_Equip#

f. Supervision and safety	#DeathForm.M2100f_Equip#

g. Advocacy or facilitation	#DeathForm.M2100g_Equip#

(M2110) Haw Often does the patient receive ADL
IADL assistance from any caregiver(s) (other
than HHA staff)?

#DeathForm.M2110_Assist_Freq#

EMERGENT CARE

(M2300)(M2301) Emergent Care: Since the last time
OASIS data were collected, has the patient
utilized a hospital emergency department
(includes holding/observation)?

#DeathForm.Emergent_Care_M0830#

(M2310) Reason for Emergent Care: For what
reason(s) did the patient receive emergent care
(with or without hospitalization)? (Mark all that
apply.)

#DeathForm.Emergent_Care_Reason_M0840#

DATA ITEMS COLLECTED AT TRANSFER/DISCHARGE ONLY

(M2400)(M2401) Intervention Synopsis: (Check only one box in each row.) Since the previous OASIS
assessment, were the following interventions BOTH included in the physician-ordered plan of care
AND implemented?

a. Diabetic foot care	#DeathForm.M2400a_Diabetic#

b. Falls prevention interventions	#DeathForm.M2400b_FallsPrev#

c. Depression intervention	#DeathForm.M2400c_Depress#

d. Intervention(s) to monitor and mitigate pain	#DeathForm.M2400d_Pain#

e. Intervention(s) to prevent pressure ulcers	#DeathForm.M2400e_PressUlc#

f. Pressure ulcer treatment based on principles of moist wound healing	#DeathForm.M2400f_PressUlcMoist#

(M2410) To which Inpatient Facility has the
patient been admitted?

#DeathForm.Inpatient_Facility_M0855#

(M2420) Discharge Disposition: Where is the
patient after discharge from your agency?

#DeathForm.Discharge_Disposition_M0870#

Discharge Page 6

#DeathForm.First_Name_M0040# #DeathForm.Last_Name_M0040#

9 - Discharge

Completed

#DateFormat(DeathForm.Assessment_Completed_M0090,"mm/dd/yyyy")#

(M2430) Reason for Hospitalization: For what
reason(s) did the patient require hospitalization?

#DeathForm.Hospital_Reason_List_M0895#

(M2440) For what Reason(s) was the patient
Admitted to a Nursing Home?

#DeathForm.Nursing_Home_M0900#

(M0903) Date of Last (Most Recent) Home
Visit

#DateFormat(DeathForm.Date_Most_Recent_M0903,"mm/dd/yyyy")#

(M0906) Discharge/Transfer/Death Date:

#DateFormat(DeathForm.Date_Discharge_M0906,"mm/dd/yyyy")#

Strengths

#DeathForm.Strengths#

Goals

#DeathForm.Goals#

Care Preference

#DeathForm.Care_Preference#

Risk Factor

#DeathForm.Risk_Factor#

Interventions

#DeathForm.Interventions#

Assessment Note

#DeathForm.Assessment_Note#

Discharge Page 7


#DeathForm.First_Name_M0040# #DeathForm.Last_Name_M0040#	9 - Discharge	Date Completed	#DateFormat(DeathForm.Assessment_Completed_M0090,"mm/dd/yyyy")#

#questions#	#Evaluate(Variables.cheked_value)# -


Recertification Page #page_num#

#DeathForm.First_Name_M0040# #DeathForm.Last_Name_M0040#

9 - Discharge

Completed

#DateFormat(DeathForm.Assessment_Completed_M0090,"mm/dd/yyyy")#

Signed by patient/legal representative as reviewed:

Patient/Representative name ________________________________________________ Date: ________________________

Patient/Representative name printed _______________________________________________________________________

Affiliation to patient (if applicable): _________________________________________________________________________

Physician Signature: ____________________________________________________

Discharge Page #page_num#