A1005: CMS OASIS Q&As

For the items in Section A that reference a proxy, the assessing clinician determines who the appropriate proxy is based on the item specific guidance and the patient’s unique circumstances. This can include but is not limited to family, caregiver, friend, Power of Attorney (POA) or health care representative.

Each OASIS item should be considered individually and coded based on guidance specific to that item. For A1005 – Ethnicity, use clinical judgment to determine if the patient is able to respond. If it is determined that the patient is unable to respond, then code X - Patient unable to respond. If it is determined that the patient is unable to respond, a proxy response may be used. If neither the patient nor a proxy is able to provide a response to this item, medical record documentation may be used. For A1010 - Race, use clinical judgment to determine if the patient is able to respond. If it is determined that the patient is unable to respond, then code X - Patient unable to respond. If it is determined that the patient is unable to respond, a proxy response may be used. If neither the patient nor a proxy is able to provide a response to this item, medical record documentation may be used. For A1255 - Transportation, use clinical judgment to determine if the patient is able to respond. If it is determined that the patient is unable to respond, a proxy response may be used. If neither the patient nor a proxy is able to provide a response to this item, medical record documentation may be used. If the patient response cannot be determined by any of these means, then code 8 - Patient unable to respond. For B1300 - Health Literacy, use clinical judgment to determine if the patient is able to respond. If it is determined that the patient is unable to respond, then code 8 - Patient unable to respond. This item is intended to be a patient self-report item. No other source should be used to identify the response for this item. For D0700 - Social Isolation, use clinical judgment to determine if the patient is able to respond. If it is determined that the patient is unable to respond, then code 8 - Patient unable to respond. This item is intended to be a patient self-report item. No other source should be used to identify the response for this item.

If information used to complete the OASIS is gathered prior to the patient’s admission this information should be verified, and coded following applicable coding guidance, during an assessment that occurs during the SOC/ROC assessment timeframe. An agency's software may not "answer" or "generate" the OASIS response for the assessing clinician. Please note that based on coding guidance, the medical record should not be used as the data source for coding Health Literacy and Social Isolation. Also note that the medical record should not be used as the data source for coding Ethnicity, Race, Language, and Transportation unless the patient and proxy are unable to respond during each specific assessment period during the applicable SOC/ROC or discharge assessment time periods.