11 Best Tips for New Nurses: Completing Your First OASIS Assessment

For new nurses entering home health care, one of the most important tasks you will encounter is completing an OASIS assessment. The Outcome and Assessment Information Set (OASIS) is a tool used to collect important information about a patient’s health. This data helps guide care, track patient progress, and ensure proper Medicare reimbursement for home health services. As a new nurse, tackling your first OASIS assessment can feel overwhelming, but with the right approach, it becomes manageable. Here are some tips to help you navigate the process smoothly and confidently.

Understanding the Purpose of OASIS

Before diving into tips for completing an OASIS assessment, it’s essential to understand what OASIS is and why it’s so important. OASIS is a standardized data collection tool used primarily in home health care settings. It gathers information about a patient’s health status, including their physical, emotional, and cognitive abilities.

The data collected through OASIS helps create a tailored care plan for each patient, ensures the patient receives the appropriate level of care, and helps determine the home health agency’s Medicare reimbursement. 

1. Take Your Time and Be Thorough

When completing your first OASIS assessment, one of the most important things to remember is to take your time. The OASIS tool is extensive and covers many aspects of a patient’s health, so it’s essential to be thorough. Rushing through the assessment could lead to incomplete or inaccurate data, which can affect the patient’s care plan and the agency’s reimbursement.

Before beginning the assessment, make sure you have all the information you need. This includes the patient’s medical history, current medications, and any other relevant documentation. Taking the time to gather all necessary details beforehand will help you complete the OASIS assessment more efficiently.

2. Build a Rapport with the Patient

As a new nurse, building a good relationship with your patients is crucial, especially when conducting an OASIS assessment. Many patients may feel uncomfortable or anxious about answering so many questions about their health. Establishing trust and rapport can make the process smoother for both you and the patient.

Start by introducing yourself and explaining what the OASIS assessment is and why it’s important. Let the patient know that the information they provide will help create a care plan that meets their specific needs. Being open, patient, and compassionate will encourage the patient to provide accurate and complete information, making your job easier.

3. Review the OASIS Questions Ahead of Time

One of the best ways to prepare for your first OASIS assessment is to review the questions ahead of time. Familiarizing yourself with the assessment will help you understand what information you need to gather and allow you to ask the right questions during your visit.

The OASIS assessment covers a wide range of topics, from the patient’s mobility and cognitive abilities to their ability to perform daily tasks like bathing and dressing. Reviewing the questions in advance helps you to feel more confident during the assessment and be better prepared to guide the conversation with your patient.

4. Ask Clear and Simple Questions

Many of the patients you will assess may be elderly or have health conditions that make it difficult for them to understand complex questions. When conducting an OASIS assessment, it’s important to ask clear and simple questions to ensure the patient can provide accurate answers.

For example, instead of asking, “How well do you perform activities of daily living?” you might say, “Can you dress yourself without help?” or “Do you need assistance when bathing?” 

5. Observe the Patient’s Abilities

While asking questions is a key part of the OASIS assessment, observing the patient’s abilities is just as important. Sometimes, patients may underreport or overestimate their abilities due to pride, embarrassment, or misunderstanding of their limitations.

As a nurse, you can gather valuable information by watching how the patient moves, walks, or performs basic tasks like getting out of bed. For example, if a patient says they don’t need help walking but you notice them struggling to move without support, make a note of this in your assessment. Your observations will help ensure the care plan is accurate and tailored to the patient’s real needs.

6. Take Detailed Notes

During your OASIS assessment, you'll need to take detailed notes. The information you collect will be used to create a care plan and may be referenced by other members of the care team. Therefore, the more detailed your notes are, the better.

Be specific when describing the patient’s abilities and limitations. For example, instead of writing “Patient has trouble walking,” you could write “Patient requires a cane to walk short distances and becomes fatigued after 10 minutes of walking.” Detailed notes will provide a clearer picture of the patient’s condition and help the care team provide more effective care.

7. Don’t Hesitate to Ask for Help

As a new nurse, it’s natural to feel uncertain when completing your first OASIS assessment. If you’re unsure about a particular question or how to assess a certain aspect of the patient’s health, don’t hesitate to ask for help. Experienced nurses or your supervisor can provide guidance and support to help you navigate the process.

Additionally, if the patient has a family caregiver, they can be a valuable resource during the assessment. Caregivers often have a deep understanding of the patient’s daily needs and can provide insights into areas where the patient may need extra support.

8. Double-Check Your Work

Once you’ve completed the OASIS assessment, take a few minutes to double-check your work. Ensure that all the questions have been answered thoroughly and that your notes are clear and complete. This extra step can help catch any mistakes or oversights and ensure that the data you submit is accurate.

Since OASIS data plays a role in determining Medicare reimbursement, inaccuracies can cause problems for the home health agency and the patient’s care. Double-checking your work will give you confidence that you’ve completed the assessment correctly.

9. Understand the Importance of Accuracy

Accuracy is key when completing an OASIS assessment. The data you collect will be used to create a care plan, track the patient’s progress, and determine the level of care the patient qualifies for under Medicare. Inaccurate or incomplete data could result in the patient receiving the wrong type of care or the agency not receiving proper reimbursement. Not only that, but it affects the plan of care contents as well when you try to create a POC from the OASIS in the home health software. So, as you can see, it affects everything.

It’s important to be as honest and objective as possible when completing the OASIS assessment. If you’re unsure about how to answer a particular question, don’t guess. Take the time to gather the information you need to provide an accurate response.

10. Use Technology to Your Advantage

Many home health agencies use electronic health records (EHRs) to manage OASIS assessments and other patient data. So, learning how to use these digital tools effectively can save you time and make the assessment process smoother.

If your agency uses a home care software system, familiarize yourself with its features and functions. Many systems allow you to input data directly into the electronic record during the assessment, reducing the need for manual paperwork. Using technology to streamline the process can help you complete the OASIS assessment more efficiently and reduce the risk of errors.

11. Be Patient and Stay Calm

Your first OASIS assessment may feel intimidating, but it’s important to stay calm and be patient with yourself. Completing an OASIS assessment is a skill that takes time to develop, and it’s normal to feel uncertain at first.

Remember that every nurse has been in your shoes at some point, and with practice, you’ll gain confidence in your ability to complete OASIS assessments accurately and efficiently.

Conclusion

Completing your first OASIS assessment can feel like a daunting task, but by following these tips, you’ll be well on your way to success. Taking your time, building rapport with the patient, asking clear questions, and observing the patient’s abilities are all essential steps in the process. Don’t be afraid to ask for help when needed, and always double-check your work to ensure accuracy. As you gain more experience with OASIS assessments, you’ll become more confident and efficient in gathering the data needed to provide high-quality care for your patients.