Clinical Quality: One Clinician Rule
Tuesday, December 5, 2017
Posted by: Mandy Rubenstein
Effective January 1, 2018, as the assessing clinician, you may elicit input from the client, caregivers, and other health care personnel, including the physician, the pharmacist and/or other agency staff to assist you in your completion of any or all OASIS items integrated within the comprehensive assessment document. For OASIS items requiring a client assessment, the collaborating healthcare providers (e.g., other agency clinical staff: LPN, PTA, COTA, MSW, HHA) should have had direct in-person contact with the patient, or have had some other means of gathering information to contribute to the OASIS data collection (health care monitoring devices, review of photograph, phone call, etc.)
When collaboration is utilized, the assessing clinician is responsible for considering available input from these other sources, and selecting the appropriate OASIS item response(s), within the appropriate timeframe and consistent with data collection guidance. M0090 (Date Assessment Completed) will indicate the last day the assessing clinician gathered or received any input used to complete the comprehensive assessment document, which includes the OASIS items.
This is from Chapter one of the Oasis Guidance Manual 2018
13. Only one clinician may take responsibility for accurately completing a comprehensive assessment. However, for all OASIS data items integrated within the comprehensive assessment, collaboration with the patient, caregivers, and other health care personnel, including the physician, pharmacist, and/or other agency staff is appropriate and would not violate the one clinician convention. When collaboration is utilized, the assessing clinician is responsible for considering available input from these other sources and selecting the appropriate OASIS item response(s) within the appropriate timeframe and consistent with data collection guidance.
Oasis Q and A regarding the one clinician rule:
In the case of an unplanned or unexpected discharge (an end of home care where no in-home visit can be made), the last qualified clinician who saw the client may complete the discharge comprehensive assessment document based on information from his/her last visit. The assessing clinician may supplement the discharge assessment with information documented from client visits by other agency staff that occurred in the last 5 days that the client received visits from the agency prior to the unexpected discharge. The “last 5 days that the client received visits” are defined as the date of the last client visit, plus the four preceding days.