Example. July 2013 Q&A #7. Q & A October 2013 Category 4 Question 5. Q&A October 2013 Category 4 Question 4

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1 1 July 213 Q&A #7 Q: Define all of the time does pain have to keep patient awake all night long in order to select it? A: At all times means constantly throughout the day and night with little or no relief. Pain is considered to interfere if patient stops activity in order to avoid pain. For pain to interfere all the time, frequency of the activity that was stopped in order to avoid pain must collectively represent all the hours of the day/night. Pain must wake them frequently at night. Clinician must use judgment based on observation and patient interview to determine if pain is interfering all the time. Example A patient is documented to have chronic arthritic joint pain that interferes with activity at least daily and is taking a pain medication daily as previously ordered. If the clinician only has orders to assess the effectiveness of the current pain medication treatment, is this order only an order to MONITOR pain (M225e no ), or would this be enough to answer yes, that we have an order to both monitor and mitigate pain? An ordered pain medication is considered an intervention to mitigate pain. Assessing for the effectiveness of the pain medication is considered an intervention to monitor pain. If both the pain medication and an order related to pain assessment are included in the physician-ordered plan of care, M225e would be Yes. 4b-Q Q&A October 213 Category 4 Question 4 Clinician assesses pt utilizing a pain scale -1, determines no pain meds used, no pain present pain is assessed at. Has this clinician utilized a standardized pain assessment tool (M124)? n YES!!! And clinician will answer 1-Yes, and it does not indicate pain 4 Q & A October 213 Category 4 Question 5 The clinician utilized a standardized -1 pain scale. No other parameters re: pain are assessed. (e.g. location, onset, etc) Can clinician state a standardized pain assessment has been conducted? M124 can be answered as YES even if a more comprehensive pain assessment was not completed. 213, Selman-Holman & Associates, LLC 1

2 M24 and Pain M1242 Frequency of Pain Interfering with patient's activity or movement: At the time of a visit, the patient reports mild pain and the nurse observes that the patient's functioning is not limited by the mild pain. The POC includes prn analgesic for pain management, which is offered, however the patient feels the pain is tolerable and elects no intervention at this time. Can I select Yes for M24d, Pain Interventions, because the intervention was ordered, offered to patient, but not felt by the patient to be needed? If there were orders to assess pain and relieve pain (prn analgesic), and record review revealed that since the previous OASIS assessment, the clinician assessed pain, and offered the analgesic, but it was never taken because of documented lack of need, as evidenced by patient's subjective comments that the pain did not warrant the medication, then M24d may be answered "Yes". The intervention was implemented when the attempt to provide it was made, and the lack of need identified. 4b-Q182.6 M1242 Frequency of Pain Interfering with patient's activity or movement: q Timepoints SOC/ROC/FU/Discharge q Identifies how often pain interferes with activities and/or treatments if prescribed q All activities, not just ADLs, e.g. sleeping, recreational activities, watching television. M1242 Frequency of Pain Interfering with patient's activity or movement: q Pain interferes with activity when the pain results In activity being performed less often than otherwise desired 4b-Q72 Requires patient to have additional assistance in performing the activity Causes the activity to take longer to complete q Medication review Pain medication 213, Selman-Holman & Associates, LLC 2

3 ClariNication of Time Period If a patient reports they have no pain currently because they have modified their activity level several weeks or months ago to exclude an activity they know will cause pain, do we answer M1242 based on the fact that they have modified their activity level (e.g., aren t even attempting to perform that activity due to the possibility of the pain returning), or do we not even consider that activity when answering the question because the patient has excluded it from their activities a long time ago. And if that is true, what would be the time frame for a long time ago? Timeframe under consideration is the day of assessment and recent pertinent past. If the patient has stopped performing an activity in order to be free of pain, the patient HAS pain that is interfering with activity. If a patient at some point stopped performing activity because of pain and there is no reasonable expectation that they could or would ever perform the activity again, an assessing clinician s judgment may determine that the activity is not considered to be in the pertinent past. Examples: stopped skiing after a knee injury 2 years ago. 4b-Q M1242 Q&A April 213 Q3: How does a physician order to immobilize a surgical extremity impact scoring of M1242? A3: If patient has stopped performing activity due to a medical restriction, not due to pain, the pain is not considered to be interfering with activity. However, if the patient is experiencing other pain that does interfere with activity or movement or restricting other activity due to pain, it would be reported in M Integumentary Status M13- M135 The OASIS manual and the opinions of the Wound Ostomy and Continence Nurses (WOCN) and the National Pressure Ulcer Advisory Panel (NPUAP) are to be used as our official guidance when documenting information about pressure ulcers and venous stasis ulcers , Selman-Holman & Associates, LLC 3

4 WOCN and NPUAP Documents Pressure Ulcer DeNined Definitions of Healing Status Definitions of Other Terms related to Wounds Definition of a Pressure Ulcer Descriptions of Pressure Ulcer Stages Definition of a Stasis Ulcer A localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. NPUAP A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. Added by WOCN 29 Stage I Pressure Ulcer Stage I Pressure Ulcer Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tone. May indicate at risk persons (a heralding sign of risk). 213, Selman-Holman & Associates, LLC 4

5 Stage I Pressure Ulcer Stage II Pressure Ulcer Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Stage II Pressure Ulcer Stage III Pressure Ulcer A Stage II ulcer also may present as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation. * Bruising indicates suspected deep tissue injury. Full thickness tissue loss. Sub-q fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. 213, Selman-Holman & Associates, LLC 5

6 Stage III Pressure Ulcer The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue; Stage III ulcers in these locations can be shallow. In contrast, areas of significant adiposity can develop extremely deep Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Stage IV Pressure Ulcer Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling Stage IV Pressure Ulcer Unstageable The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue; Stage IV ulcers in these locations can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (eg, fascia, tendon, or joint capsule); osteomyelitis is possible. Exposed bone/ tendon is visible or directly palpable. q Known or likely but not stageable due to non-removable dressing or device q Includes those that are sutured q Includes those with skin grafts that edges haven t healed yet q Known or likely but not stageable due to coverage of wound bed by slough and/or eschar. q Suspected deep tissue injury in evolution. 213, Selman-Holman & Associates, LLC 6

7 Unstageable #d2 Unstageable #d2 Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed may render a wound unstageable. Further description. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth (and therefore, the stage) cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the body s natural (biological) cover and should not be removed. Suspected Deep Tissue Injury Suspected DTI Suspected deep tissue injury in evolution, which is defined by the NPUAP as a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. 213, Selman-Holman & Associates, LLC 7

8 Healing DeNined: Stage I and Stage II Pressure Ulcers q Stage I and Stage II (partial thickness) pressure ulcers can heal through the process of regeneration of the epidermis across a wound surface, known as epithelialization. NPUAP 24 q Once healed, a Stage I or II is no longer present. Healing DeNined: Stage III and Stage IV Pressure Ulcers Stage III and IV (full thickness) pressure ulcers heal through a process of contraction, granulation, and epithelialization. They can never be considered "fully healed" but they can be considered closed when they are fully granulated and the wound surface is covered with new epithelial tissue. Once closed, a Stage III or IV is still present. AND still requires active intervention to avoid break down. q Do not reverse stage Pressure Ulcer General Guidance q A muscle flap, *skin advancement flap, or rotational flap performed to surgically replace a pressure ulcer is a surgical wound and is no longer a pressure ulcer. q A pressure ulcer that has been surgically debrided remains a pressure ulcer. It does not become a surgical wound. q A pressure ulcer with a skin graft is still a pressure ulcer. Pressure Ulcers (2 nd q 212) Stage II pressure ulcer at SOC that is now closed and only red No reverse staging! Not a Stage 1 If reepithelialized and healed then not reported. If a new non-blanching erythema at the site where the Stage 2 healed, this is a new Stage , Selman-Holman & Associates, LLC 8

9 Issue on Pressure Ulcers with Skin Grafts q Pressure ulcer with a skin graft is a pressure ulcer. q Also cannot visualize the wound bed to be able to stage. q So what to do with a pressure ulcer covered with a skin graft?? q Unepithelialized edges = unstageable by presence of device or graft q Edges epithelialized = closed ulcer at original stage Pressure Ulcer General Guidance q Unhealed: The absence of the skin s original integrity. (includes closed Stage III and Stage IV) q Non-epithelialized: The absence of regenerated epidermis across a wound surface. M13 Pressure Ulcer Assessment M132 Risk of Developing Pressure Ulcers Process Measure July 213 Q&A #8 36 Q: If patient had a Stage IV pressure ulcer and the post-op surgical report says it was surgically excised and closed without placement of a muscle flap, do we still have a Stage IV pressure ulcer or did this become a surgical incision? A: If all the tissue damaged by pressure is removed surgically, e.g. amputation or surgical excision, there is no longer a pressure ulcer. It becomes a surgical wound until healed. 213, Selman-Holman & Associates, LLC 9

10 37 July 213 Q&A #9 Q: Patient has a Stage III pressure ulcer that is covered with a scab at reassessment. How does the scab affect staging? A: Refer to WOCN guidance. If pressure ulcer has full-thickness tissue loss and can see bone, muscle or tendon then it has advanced to Stage IV, regardless of presence of eschar, slough or scab. If no bone, muscle or tendon is visible and clinician judges the amount/placement of any necrotic tissue or scab could not be obscuring visualization of Stage IV structures, pressure ulcer is a Stage III. 38 July 213 Q&A #9 continued. A (con t): If the clinician believes the necrotic tissue/scabbing may be obscuring visualization of bone, muscle or tendon then the pressure ulcer is unstageable. In the unusual situation of an unstageable scabbed pressure ulcer, report the pressure ulcer in M138 row d2 known or likely but unstageable due to coverage by slough or eschar. Note that a scab is not slough or eschar, but due to constraints of data set the unstageable scabbed pressure ulcer must be reported in this manner. Documentation in medical record will describe the clinical findings. 39 July 213 Q&A #1 Q: for M132, what is the healing status of a Stage IV pressure ulcer that has closed to the point it has a scab on the surface? It is not eschar or slough. A: Refer to WOCN guidance. Can t be because wound bed is not completely covered by new epithelium. If scab is raised and appears to be covering a wound that has filled with granulation tissue to the level of surrounding skin could be a 1, but NOT if scab prevents you from visualizing if the wound bed is filled with granulation tissue. 4 July 213 Q&A #1 A (con t): If the scab is present over a wound bed that is sunken below the level of surrounding skin, then cannot be or 1. If there are no s/sx of infection and you can visualize that at least 25% of the wound bed is covered with granulation tissue, then select response 2. The scab is not avascular tissue (eschar or slough) so the criteria of <25% of wound bed covered with avascular tissue does not apply. If the scab covered wound has any of the criteria for not healing then report as a , Selman-Holman & Associates, LLC 1

11 M13 Pressure Ulcer Assessment q Timepoints SOC ROC q Identifies patient s risk of developing pressure ulcers q CMS does not require the use of standardized tools, nor does it endorse one particular tool. q This item is used to calculate process measures to capture the agency s use of best practices q The best practices stated in the item are not necessarily required in the CoPs M13 Pressure Ulcer Assessment q If Response to M13 was (No pressure ulcer risk assessment) note skip pattern q Use of validated standardized screening tool Use the scoring parameters to identify if a patient is at risk for developing pressure ulcers q If tool does not define levels of risk or if eval was based on clinical factors (w/o a validated standardized screening tool), then the care provider may define what constitutes risk M13 Pressure Ulcer Assessment Response 1--Patient's risk for pressure ulcer development was clinically assessed, but no formal pressure ulcer screening tool was used. Response 2--Formal standardized tool was used. M13 If a patient scores no risk on the Braden Scale but the RN performs an evaluation of clinical factors and determines the patient is at risk for pressure ulcers, how do we answer M13? 4b-Q , Selman-Holman & Associates, LLC 11

12 45 New Answer Jan. 213 Q&A The response to M13 should be 2-Yes, using a standardized tool, e.g., Braden, Norton, other if a standardized, validated tool assessment tool, e.g., Braden, Norton, was utilized, regardless of whether another non-standardized tool or clinical evaluation was also conducted. If both a standardized pressure ulcer assessment AND an evaluation of clinical factors were conducted, the response to M132 should be 1-Yes if either the clinical evaluation or the standardized tool is positive for risk. M136 Unhealed Pressure Ulcer at Stage II or Higher M136 Unhealed Pressure Ulcer at Stage II or Higher q Timepoints SOC/ROC/FU/DC q Select Response 1 Yes, if the patient has an q unhealed Stage II, OR q a Stage III, or Stage IV pressure ulcer at any healing status level OR q if the patient has an unstageable ulcer(s) Response No if The only pressure ulcer(s) is Stage 1 OR if a former Stage 2 pressure ulcer has healed AND the patient has no other pressure ulcers 48 M136 Q & A January 214 Category 4b Question # 6 If at the SOC visit, the assessing clinicain observes an open ulcer over a bony prominence, with history of pressure and visible bone, can the clinician report this as a Stage IV P/ U, even if not able to get confirmation of the dx from the physician prior to completing the assessment? 213, Selman-Holman & Associates, LLC 12

13 At SOC, the assessing clinician responsible for completing the SOC comprehensive assessment must have visualized the wound in order to include it as a Stage IV P/U in the SOC OASIS P/U items. These items are a report of the clinician s integumentary status assessment findings. A P/U may be reported on OASIS based on visualization of the wound, patient assessment and interview and review of relevant related historical documentation. Although the assessing clinician can report the observed ulcer on the OASIS w/o physician confirmation, collaboration with the physician would be required in order to receive related orders and /or provide physician ordered care related to the P/U The discussion re: this response: I am reading this as: the clinician can mark a pressure ulcer on the OASIS items based solely on her assessment, does not require the diagnosis of a pressure ulcer to be documented on the referral or H&P and the diagnosis does not have to be verified by the physician to mark it on the OASIS M The guidance on coding diagnoses is that all diagnoses must be documented in the medical record or verified with the physician; the clinician cannot assume a diagnosis based on medications or reported history from patient, and wound etiology must be documented in the referral/ H&P or confirmed with physician. More to come on this situation watch Lisa s blog for additional info. M137 The Oldest Non- epithelialized Stage II Pressure Ulcer M137 The Oldest Non- epithelialized Stage II Pressure Ulcer Timepoints Discharge Intent of this item Assess the length of time the Stage II ulcer remained unhealed while the patient received care from the home health agency Stage 2 pressure ulcers generally heal within 3 days Identify patients who develop Stage II pressure ulcers while under the care of the agency. 213, Selman-Holman & Associates, LLC 13

14 53 M137 Stage II at discharge assessment could have been a Stage I or unstageable at SOC/ROC, just had to be present at SOC/ROC An ulcer that is suspected of being a Stage II, but is unstageable, should not be identified as the oldest Stage II pressure ulcer at discharge M138 Current Number of Unhealed (non- epithelialized) Pressure Ulcers at Each Stage M138 Current Number of Unhealed (non- epithelialized) Pressure Ulcers at Each Stage M138 Current Number of Unhealed (non- epithelialized) Pressure Ulcers at Each Stage Clinician should make every effort to determine the wound s most severe stage Contact previous providers Contact physician There are exceptions if unstageable now An ulcer's stage can worsen, and this item should be answered appropriately if this occurs. Although the wording in M138 includes the term non epithelialized, for this item, a closed Stage III or Stage IV pressure ulcer should be reported as a pressure ulcer at its worst stage, even if it has reepithelialized. An epithelialized stage II is not reported. Why? 213, Selman-Holman & Associates, LLC 14

15 Exercise: Patient has no Stage II on admission but has a Stage II at FU. Exercise: Patient has no Stage II on admission but has a Stage II at FU. A L L Z E R O E S 1 Z E R O Z E R O E S M138 Current Number of Unhealed (non- epithelialized) Pressure Ulcers at Each Stage Exercise: Patient has a Stage III on admission that is a Stage IV at FU Patient has no Stage II pressure ulcers on admission, but develops one during the first episode that is present at the time of follow-up. In this case, row a, column 1 would be at SOC. At follow-up, row a, column 1 would be 1 and row a column 2 would be, indicating the pressure ulcer was not present on admission , Selman-Holman & Associates, LLC 15

16 Exercise: Patient has a Stage III on admission that is a Stage IV at FU M138 Current Number of Unhealed (non- epithelialized) Pressure Ulcers at Each Stage 1 1 Example 2: Patient has a Stage III pressure ulcer on admission that is assessed to be a Stage IV at follow-up. In this case, row b, column 1 would be 1 at SOC. At follow-up, row b, columns 1 and 2 would both be, as the patient no longer has a Stage III ulcer. Row c, column 1 would be 1 and column 2 would be 1 indicating the ulcer was present on admission, even though it was at a different stage. Exercise: Stage II on admission that heals within the Nirst 2 weeks, but then develops another stage II prior to DC at week 4. Exercise: Stage II on admission that heals within the Nirst 2 weeks, but then develops another stage II prior to DC at week 4. 1 A L L Z E R O ES 1 Z E R O E S Z E R O E S 213, Selman-Holman & Associates, LLC 16

17 M138 Current Number of Unhealed (non- epithelialized) Pressure Ulcers at Each Stage Example 3: Patient has a Stage II pressure ulcer on admission that heals within the first 2 weeks, but then develops another Stage II pressure ulcer prior to discharge at week 4. In this case, row a, column 1 would be 1 at SOC. At Follow-up, row a, column 1 would be 1 and row a, column 2 would be, indicating the pressure ulcer that is present at follow up or discharge was not present on admission. For both Columns 1 and 2: Mark a response for each row of this item: a, b, c, d1, d2, and d3. If there are NO ulcers at a given stage, enter for that stage. M138 ROC & Recert Mrs. I. M. Onabiggawound was released from the hospital on day 57 of the episode. You will be completing the ROC assessment and you know that it will also serve as the Recertification assessment. She has a stage III pressure ulcer. Will you complete column 2 (Current Number of Unhealed Pressure Ulcers at Each Stage) on M138 or will you leave column 2 blank? How to Complete M138 on the ROC/ Recert 1 Z E R O E S L E A V E B L A N K 68 M138 Q&A April 213 Q4: Patient had a closed Stage IV pressure ulcer at SOC. Two weeks later, it appeared to be a shallow open ulcer. Can I report it as a Stage II or is it a non-observable Stage IV because I can t visualize bone, muscle or tendon? 213, Selman-Holman & Associates, LLC 17

18 69 M138 Q&A April 213 A4: A previously closed Stage III or Stage IV pressure ulcer that opens again should be reported as its worst stage. As long as the wound bed is free of slough and eschar, it may be reported as a Stage IV. If slough or eschar is present, obscuring the wound bed, it may not be staged and is reported in M138 as d.2: known or likely but unstageable due to coverage of wound bed by slough and/or eschar. **This is also true if wound is covered by a scab** Provide supportive documentation in narrative (Q&A Oct. 213) 7 Q&A October 214 Category 4 Question #6 Note that a scab is not slough or eschar, but due to the constraints of the data set, the unstageable scabbed pressure ulcer must be reported in this manner. M132-Status of most problematic wound continue to refer to WOCN guidance. (see add l handout prn) M139 M139 Change Description 71 Worsening in Pressure Ulcer Status since SO/ROC: Indicate the number of current pressure ulcers that were not present or were at a lesser stage at the most recent SOC/ROC (Enter if none) 72 Collects information at D/C which was previously collected in M138 column 2 on worsening pressure ulcer status, and harmonized with MDS and CARE instruments. 213, Selman-Holman & Associates, LLC 18

19 M131, M1312, M1314 Largest Surface Dimension Length M131, Width M1312, and Depth M1314 Timepoints SOC ROC Discharge Complete these items only if M138 Column 1, rows b, c, or d.2 is greater than. Otherwise, leave these items blank. (Stage III, IV or unstageable due to eschar or slough) Ignore non-epithelialized Surface area = length x width Record in centimeters (to the nearest 1 th of a centimeter) Length M131, Width M1312, and Depth M1314 Acceptable means of wound measurement Disposable measuring device e.g. cottontipped applicator Camera Other wound technology that calculates measurements Note: If you can visualize it, measure it!! Even if all you see is a wound bed that is 1% covered with slough/eschar. Length M131, Width M1312, and Depth M1314 If all existing Stage III or IV pressure ulcers are closed (completely re-epithelialized) and the patient has no pressure ulcers that are unstageable due to coverage of the wound bed by slough and/or eschar, enter. for M131, M1312, and M1314 Non-epithelialized unstageable (due to the presence of slough or eschar as reported in M138 d.2) Stage III or IV must be measured Determine which has largest surface dimension (L x W) Do not consider depth (.) 213, Selman-Holman & Associates, LLC 19

20 When measuring a P/U depth does depth include the depth of a tunnel? When measuring the depth of a pressure ulcer report the depth from the visible surface to the deepest area in the base of the wound, which does not include the depth of any tunneling present. Best Practices, as recommended by the WOCN pressure ulcer Guidelines would encourage documentation within the comprehensive assessment of additional details regarding the wound that are not reported in specific OASIS items, including presence, location and depth of sinus tracts or undermined areas. 4b-Q M132 Status of Most Problematic (Observable) Pressure Ulcer Newly epithelialized The process of regeneration of the epidermis across a wound surface wound bed completely covered with new epithelium no exudate no avascular tissue (eschar and/or slough) no signs or symptoms of infection 213, Selman-Holman & Associates, LLC 2

21 Fully Granulating q wound bed filled with granulation tissue to the level of the surrounding skin q no dead space q no avascular tissue (eschar and/or slough) q no signs or symptoms of infection q wound edges are open Early/Partial Granulation q 25% of the wound bed is covered with granulation tissue q < 25% of the wound bed is covered with avascular tissue (eschar and/ or slough) q no signs or symptoms of infection q wound edges open Not Healing q 25% avascular tissue OR q S/S of infection OR q Clean but non granulating wound bed OR q Closed/hyperkeratotic wound edges OR q Persistent failure to improve despite appropriate comprehensive wound management M132 Status of Most Problematic (Observable) Pressure Ulcer: q Timepoints SOC/ROC/DC q Identifies the degree of healing visible in the most problematic observable pressure ulcer, stage II or higher. (Stage Is are not considered.) q Visualization of the wound is necessary to identify the degree of healing evident in the ulcer identified in M , Selman-Holman & Associates, LLC 21

22 M132 Status of Most Problematic (Observable) Pressure Ulcer: Most problematic May be the largest The most advanced stage The most difficult to access for treatment The most difficult to relieve pressure, etc., If the patient has only one observable pressure ulcer, then that ulcer is the most problematic. M132 Status of Most Problematic (Observable) Pressure Ulcer: Response Newly epithelialized Tissue has completely covered the wound surface of the pressure ulcer Regardless of how long the pressure ulcer has been re-epithelialized. This is an appropriate response for Stage III and IV pressure ulcers, but not for Stage II ulcers as fully epithelialized Stage II ulcers should not be reported. M132 Status of Most Problematic (Observable) Pressure Ulcer: Response 1 Fully Granulating Stage III or IV that epithelial tissue has not completely covered the wound surface Response 3 - Not healing Stage II Do not granulate, therefore, must be reported as Response 3 not healing Suspected deep tissue injury that has not evolved is considered not healing. M132 Status of Most Problematic (Observable) Pressure Ulcer: NA- No observable pressure ulcer Includes only those that cannot be observed due to the presence of a dressing or device that cannot be removed (including casts). When determining the healing status of a pressure ulcer for answering M132, the presence of necrotic tissue does NOT make the pressure ulcer NA No observable pressure ulcer. 213, Selman-Holman & Associates, LLC 22

23 M132 Status of Most Problematic (Observable) Pressure Ulcer: A pressure ulcer with necrotic tissue (eschar/slough) obscuring the wound base cannot be staged, but its healing status is either Response 2 Early/partial granulation if necrotic or avascular tissue covers <25% of the wound bed, or Response 3 - Not healing, if the wound has 25% necrotic or avascular tissue. Just Almost Closed My patient has a Stage III pressure ulcer that is closing. How do I report the stage and status when the opening has shrunk to a pinpoint size and does not present a viewable base due to the small opening? If you have a Stage III that is in the process of closing, it remains an observable Stage III unless the wound bed was covered with a dressing that could not be removed or the wound bed was obscured with avascular tissue. If the wound margins are open and have now closed to the point where the opening is a pinpoint, the pressure ulcer would remain a Stage III. The status could be either Early/partial granulation or Fully granulating, based on the descriptors in the WOCN Guidance on OASIS-C Integumentary Items, until the wound margins closed, at which time it would be considered a newly epithelialized Stage III pressure ulcer. 4b-Q99.3 M1322 Current Number of Stage I Pressure Ulcers M1324 Stage of the Most Problematic Unhealed (observable) Pressure Ulcer q Timepoints SOC/ROC/FU/ Discharge q NRS 213, Selman-Holman & Associates, LLC 23

24 M1324 Stage of Most Problematic Unhealed (Observable) Pressure Ulcer Timepoints SOC/ROC/FU/Discharge Must be able to visualize ulcer Determine the most problematic pressure ulcer Identify the degree of damage evident in the ulcer. If the patient has only one observable pressure ulcer, then that ulcer is the most problematic. M1324 Stage of Most Problematic Unhealed (Observable) Pressure Ulcer Follow NPUAP to make determination--no reverse staging!! NA NO pressure ulcers Pressure ulcers cannot be observed due to necrotic tissue (including eschar or slough) that obscures visualization of the wound base n A pressure ulcer that is covered with slough or eschar cannot be staged until the wound bed is visible (even if previously staged) 4b-Q Non-removable dsg or cast Until the SDTI evolves and opens, the Stage will be considered NA, as the wound bed cannot be visualized NA M132 v. M1324 The SpeciNics on Sutured Pressure Ulcers 95 M132 Healing Status Only those covered with non-removable dressing or device M1324 Stage Non-removable dressing or device Eschar and/or slough SDTI not evolved How do I categorize a pressure ulcer that has been sutured closed? Since it is relatively uncommon to encounter direct suture closure of a pressure ulcer, it is important to make sure that the pressure ulcer was not closed by a surgical procedure (such as a skin advancement flap, rotation flap, or muscle flap). A pressure ulcer that is sutured closed (without a flap procedure) would still be reported as a pressure ulcer. While this approach (direct suture closure) may rarely be attempted due to a low success rate, home care providers are reporting occurrence. 4b-Q , Selman-Holman & Associates, LLC 24

25 Sutured Pressure Ulcer Since the pressure ulcer is sutured closed, the pressure ulcer is considered unstageable. X Treated as unstageable due to nonremovable dressing or device. 4b-Q89.2 M138-d1 M131-M1314-Leave blank M132-NA M1324-NA The SpeciNics on Pressure Ulcers With Skin Grafts Mrs. Rose was admitted for aftercare post skin graft of a Stage III pressure ulcer of the hip with orders for the pressure dressing to remain in place until the patient s first office visit. What will you report at the SOC assessment for M138, M132, and M1324? 4b-Q98.5 M138 d1 M132 NA M1324 NA Pressure Ulcers/Skin Grafts/Healed CMS Q&A July21 Pressure Ulcers/Skin Grafts/Healed At Discharge, Mrs. Rose s graft site has healed with some contracture and discoloration of the grafted site, and full epithelialization what is the appropriate response for M138, M132, and M1324? 4b-Q Z E R O E S 213, Selman-Holman & Associates, LLC 25

26 Pressure Ulcers/Skin Grafts/Healed Pressure Ulcers/Skin Grafts/Healed X X This pressure ulcer is covered with epithelial tissue. This pressure ulcer is a closed Stage III. M133 Does this patient have a Stasis Ulcer? M133 Does this patient have a Stasis Ulcer? Timepoints SOC/ROC/FU/Discharge Information may be obtained from the physician or patient/ caregiver regarding the presence of a stasis ulcer underneath the cast or dressing. Venous Stasis Ulcers Defined Ulcers caused by inadequate venous circulation Usually lower legs medial side Often associated with stasis dermatitis Stasis ulcers DO NOT include arterial lesions or arterial ulcers May need to contact physician for clarification. 213, Selman-Holman & Associates, LLC 26

27 15 M133 Q&A Jan 213 Our patient s lower extremity wound originated as a trauma wound due to a fall. The patient also has diagnoses of venous insufficiency and stasis dermatitis. The physician stated the wound is not healing due to the venous insufficiency. Is there a point in time when the wound is no longer classified as a traumatic wound and considered a stasis ulcer for M133? M133, Does this patient have a Stasis Ulcer? identifies patients with ulcers caused by inadequate circulation in the area affected. The healing process of other types of wounds, e.g. traumatic wounds, surgical wounds, burns, etc., may be impacted by the venous insufficiency, but it would not change the traumatic or surgical wound into a venous stasis ulcer. M1332 Current Number of (Observable) Stasis Ulcer M1332 Current Number of (Observable) Stasis Ulcer(s) M1334 Status of Most Problematic (Observable) Stasis Ulcer q Timepoints SOC/ROC/FU/Discharge q All stasis ulcers except those that are covered by a nonremovable dressing or cast are considered observable. 213, Selman-Holman & Associates, LLC 27

28 M1334 Status of Most Problematic (Observable) Stasis Ulcer q Timepoints SOC/ROC/FU/Discharge q Identifies the degree of healing present in the most problematic, observable stasis ulcer. q If the patient has only one stasis ulcer, that ulcer is the most problematic. q Do not use Newly epithelialized! q Stasis ulcers, once epithelialized, are no longer stasis ulcers. M134 Does this patient have a Surgical Wound? Timepoints SOC/ROC/FU/Discharge Old surgical wounds that have resulted in scar or keloid formation are not considered current surgical wounds and should not be included in this item. M134 Does this patient have a Surgical Wound? For the purpose of this OASIS item, a surgical site closed primarily (with sutures, staples or a chemical bonding agent) is generally described in documentation as a surgical wound until re-epithelialization has been present for approximately 3 days, unless it dehisces or presents signs of infection. M134 Does this patient have a Surgical Wound? q After 3 days, it is generally described as a scar and should not be included in this item. If the home health clinician conducting the assessment is not sure the wound fits the definition of a surgical incision, the clinician should contact the physician for clarification. q How many days since surgery? 213, Selman-Holman & Associates, LLC 28

29 Determining the Healing Status of a Surgical Wound "Epidermal resurfacing" means the opening created during the surgery is covered by epithelial cells. If epidermal resurfacing has occurred completely, the correct response in the OASIS would be "Newly epithelialized", until 3 days have passed without complication, at which time it is no longer a reportable surgical wound. If it hasn t been 3 days since epithelialization, then Newly epithelialized 4b-Q Q & A January 214 Category 4b M 134 Q--Our patient had skin cancer treated with electrodessication and curettage, creating a lesion. Is this considered a surgical wound when completing M134, Surgical Wounds? A--Yes Q & A January 214 Category 4b Question # 7 Q & A January 214 Category 4b Question # 7 continued 115 Q-- A pt. had a PICC inserted centrally into the internal jugualr. Is this considered a central line when scoring M134, Surgical Wounds? A Central venous catheters or central lines are those w/ the cathetere tip located in the superior vena cava. Central lines can be peripherally inserted (i.e. basilic or cephalic vein in upper arm, 116 or femoral vein in the groin) or centrally inserted (i.e. interanl jugular vein in the neck, or sub-clavian or axillary vein in the chest). Central lines that are centrally inserted (as in the internal jugular example) ARE considered surgical wounds for M134 because of the central insertion even if the type of catheter inserted into the central vein was intended to be inserted peripherally. Central lines that are peripherally inserted are not considered surgical wounds. 213, Selman-Holman & Associates, LLC 29

30 Q & A January 214 Category 4b Q# Mrs. Downton has an intra-abdominal abscess that was drained in the ED. The physician was able to drain the abscess percutaneously and then placed a JP drain at the site. Will this be listed as a surgical wound on the SOC? Yes, it will be a surgical wound. WHY?? It is considered a surgical wound because of the placement of the JP drain Examples of Surgical Wounds 4b- Q12-16 Examples of Surgical Wounds 119 Surgical Wounds Not Surgical Wounds 12 Surgical Wounds Not Surgical Wounds Pressure ulcers with muscle flaps Dialysis cath exit sites Implanted infusion devices ON-Q catheter sites Implanted pumps Cardiac cath by cutdown Pressure ulcers with skin grafts Pressure ulcers sutured closed Paracentesis 4b-Q15.6 PICC line (tunneled and non-tunneled) Cardiac cath by needle puncture Toenail removal I&D with drain Excision Wound with drain even after drain pulled Shave, punch or excisional biopsy Repair of a internal trauma Take down of ostomy I&D without drain Removal of a callus Repair of a traumatic laceration Burn with a skin graft Thoracotomy or any wound ending is otomy (ostomy) Ostomy allowed to close on its own 213, Selman-Holman & Associates, LLC 3

31 Examples of Surgical Wounds Surgical Wound or Thoracotomy? 121 Surgical Wounds Pacemakers until epithelialized for 3 days VP shunt Donor site for grafts Arthroscopy Not Surgical Wounds Pacemakers once epithelialized for 3 days Retention sutures, staple sites Cataract surgery Gynecological surgery via vaginal approach Mucous membranes (dental) q A surgical incision was created to perform exploratory surgery. When closing the wound, the surgeon inserted a chest tube utilizing the opening created for the surgery. Can this closed incision with a chest tube be counted as a surgical wound when completing M134? q The wound described should be considered a thoracostomy and is not considered a surgical wound when completing the OASIS data set item M134. 4b-Q M134: Q&A #12 July 213 Q: Is the VANTAS implant considered a surgical wound? A: The VANTAS implant is inserted just under the skin of upper arm, provides continuous 12 month administration of histrelin acetate for palliative treatment of advanced prostate cancer. It is considered a surgical wound from the time the surgical incision is made to implant the device until the implant device is removed. X Mammosite Device in a Lumpectomy Site Receives radiation bead insertion through this catheter X 213, Selman-Holman & Associates, LLC 31

32 Kyphoplasty If the kyphoplasty procedure was performed percutaneously and resulted in a pinpoint needle puncture site where the bone cement was injected, it would not be considered a surgical wound. If the kyphoplasty procedure involved an open approach, requiring a surgical incision, the resulting wound would be considered a surgical wound for M134. M1342 Status of Most Problematic (Observable) Surgical Wound Status of healing definitions apply to surgical wounds healing by primary intention and to those healing by secondary intention. M1342 Status of Most Problematic (Observable) Surgical Wound Newly epithelialized Timepoints SOC/ROC/FU/Discharge Patient has only one observable surgical wound, that wound is the most problematic Most problematic may be Largest Most resistant Infected surgical wound, etc., depending on the specific situation. q wound bed completely covered with new epithelium q no exudate q no avascular tissue (eschar and/or slough) q no signs or symptoms of infection q (Newly epithelialized for 3 days when closed by primary intention) 213, Selman-Holman & Associates, LLC 32

33 Fully Granulating Early/Partial Granulation q wound bed filled with granulation tissue to the level of the surrounding skin q no dead space q no avascular tissue (eschar and/or slough) q no signs or symptoms of infection q wound edges are open q 25% of the wound bed is covered with granulation tissue q < 25% of the wound bed is covered with avascular tissue (eschar and/ or slough) q no signs or symptoms of infection q wound edges open 25% avascular tissue OR S/S of infection OR Clean but non granulating wound bed OR Closed/hyperkeratotic wound edges OR Persistent failure to improve despite appropriate comprehensive wound management Not Healing Guidance on Surgical Wounds Healing by Primary Intention Surgical incisions healing by primary intention do not granulate. Because of this the only response that could be appropriate for a surgical wound healing by primary intention would be: -Newly epithelialized or 3-Not healing. 4b-Q Newly epithelialized should be chosen if the surgical incision has epidermal resurfacing across the entire wound surface, and no signs/symptoms of infection exist. 213, Selman-Holman & Associates, LLC 33

34 Implanted Venous Access Devices Response For implanted venous access devices and infusion devices when the insertion site is healed. When first implanted, the incision is the surgical wound. The assessing clinician will follow the 12/9 WOCN guidance to determine the healing status of the incision. Once it is fully epithelialized, the site due to the implanted device will remain a current surgical wound with a status of Newly epithelialized" for as long as it is present in the patient's body, unless it later develops complications. 4b-Q15.3 Guidance on Vascular Access Devices If an extremely large bore needle or traumatic entry or removal occurs there may be a resulting wound that heals by secondary intention. A scab may mean that full epithelialization has not occurred, therefore look to WOCN guidance to determine healing status. 4b-Q112.6 Some sites, because they are being held open by a drain, line or needle, cannot fully granulate and may remain "non-healing" while the drain, line or needle is in place. 4b-Q Determining the Healing Status of a Surgical Wound 1 st Determine if the surgical incision is healing by: Primary Intention: Edges well approximated OR Secondary intention: Due to dehiscence or interruption of the incision. If the wound is healing solely by primary intention, the assessing clinician will observe if the incision line has reepithelialized. (If there is no interruption in the healing process, this generally takes from a matter of hours to three days.) If there is not full epithelial resurfacing, such as in the case of a scab adhering to underlying tissue, then the correct response would be "not healing" for the wound healing by primary intention. Determining the Healing Status of a Surgical Wound The presence of a scab does not automatically equate to a "not healing" response. The clinician must first assess if the wound is healing entirely by primary intention (complete closure with no openings), or if there is a portion healing by secondary intention. If it is determined that there is incisional separation, healing will be by secondary intention, and the clinician will then have to determine the status of healing, which may be "Not healing "Early/partial granulation "Fully granulating" and eventually "Newly epithelialized". 213, Selman-Holman & Associates, LLC 34

35 Wound Healing by Secondary Intention M135 Does this patient have a Skin Lesion or Open Wound, other than M135 Does this patient have a Skin Lesion or Open Wound Timepoints SOC/ROC/FU/Discharge Identifies the presence or absence of a skin lesion or open wound NOT ALREADY ADDRESSED IN PREVIOUS ITEMS that is receiving clinical assessment or intervention from the home health agency. Does not include: bowel ostomies, pressure ulcers, stasis ulcers and surgical wounds Does include: peripheral IVs, all other ostomies, all other skin lesions and open wounds n But only as long as those skin lesions or open wounds require assessment or intervention M135 Does this patient have a Skin Lesion or Open Wound A lesion is a broad term used to describe an area of pathologically altered tissue Sores Skin tears Burns Ulcers (except pressure and stasis) Rashes Diabetic ulcers Cellulitis Abscesses Wounds caused by trauma of various kinds, etc. Primary lesions, secondary lesions, changes in shape (edema), texture, color, breaks in skin and vascular lesions 4b-Q , Selman-Holman & Associates, LLC 35

36 M135 Does this patient have a Skin Lesion or Open Wound Skin lesions or open wounds that are not receiving clinical intervention from the home health agency should not be considered when responding to this question. Any skin condition that is being clinically assessed on an ongoing basis as indicated on the POC (e.g., wound measurements), should be answered Yes. M135 Does this patient have a Skin Lesion or Open Wound PICC line and peripheral IV sites are considered skin lesions / open wounds. Ostomies, other than bowel ostomies, (e.g., tracheostomy, thoracostomy, urostomy) ARE considered to be skin lesions or open wounds if clinical interventions (e.g., cleansing, dressing changes) are being provided by the home health agency during the home health care episode. M135 Excludes Bowel Ostomies Excludes bowel ostomies means those ostomies that are used for bowel elimination. Gastrostomies and jejunostomies are not considered bowel ostomies. (G tubes and J tubes are reported in M135) 4b-Q M135 Does this patient have a Skin Lesion or Open Wound This item does not address/include cataract surgery surgery to mucosal membranes gynecological surgical procedures by a vaginal approach. This item does not address/include tattoos Piercings Or other skin alterations unless ongoing assessment and/or clinical intervention is ordered on the POC 213, Selman-Holman & Associates, LLC 36

37 Quiz 145 Our patient had a burn with orders for the nurse to assess and change the dressing twice weekly. The patient is leaving the geographical area. The PT is making the last visit and completing the Discharge comprehensive assessment. She will not be changing the burn dressing on the discharge visit. How do we answer M135? Is M135 asking whether or not the agency provided intervention to the wound on the day of discharge or is it asking whether or not the patient had a wound on the day of assessment that required intervention from the agency, even though they didn't receive a specific intervention on the day of the discharge? 4b-Q Intervention does not have to be performed on THAT day. 146 Respiratory Status M14s RESPIRATORY STATUS M14 When is the patient dyspneic or noticeably Short of Breath? M14 When is the patient dyspneic or noticeably Short of Breath? Timepoints SOC/ROC/FU/Discharge How to assess? If patient uses oxygen continuously n Assess with oxygen in use If the patient uses oxygen intermittently n Assess without the use of oxygen What if ordered continuously but only used intermittently? Sleep apnea dyspnea 213, Selman-Holman & Associates, LLC 37

38 M14 When is the patient dyspneic or noticeably Short of Breath? Chairfast or bedbound patient: Evaluate the level of exertion required to produce shortness of breath The chairfast patient can be assessed for level of dyspnea while performing ADLs or at rest Response n Patient has not been short of breath during the day of assessment M14 When is the patient dyspneic or noticeably Short of Breath? Chairfast or bedbound patient: Response 1 (When walking more than 2 feet ) Appropriate if demanding bed-mobility activities produce dyspnea in the bedbound patient (or physically demanding transfer activities produce dyspnea in the chairfast patient). Responses 2, 3, and 4 for assessment examples for these patients as well as ambulatory patients. M141 Respiratory Treatments M141 Respiratory Treatments Timepoints SOC/ROC/Discharge Excludes any respiratory treatments that are not listed in the item Does not include nebulizers, inhalers Option 3 reflects both CPAP and BiPAP. 213, Selman-Holman & Associates, LLC 38

39 M141 Respiratory Treatments You are completing a D/C OASIS on Mr. Martinez. The 485 includes a PRN order for oxygen via n/c. You have reviewed the chart and noticed there was no mention of oxygen use on any skilled notes. You interview the patient and the caregiver and they state oxygen has not been used since Mr. Martinez s admission to home health. 4b-Q114.2 How will you answer M141- Respiratory Treatments (oxygen, ventilator, CPAP, BiPAP) utilized at home? 154 Cardiac Status M15s X M15 Symptoms in Heart Failure Patients M15 Symptoms in Heart Failure Patients q Identifies if patient has experienced signs/ symptoms of heart failure at time of most recent OASIS assessment or since that time q Used to calculate process measures to capture the agency s use of best practices q The best practices/assessments stated in the item are not necessarily required in the Conditions of Participation. 213, Selman-Holman & Associates, LLC 39

40 M15 Symptoms in Heart Failure Patients Timepoints Transfer Discharge If patient has a diagnosis of heart failure in M11 Inpatient Diagnosis M116 Diagnoses Causing Chg in Treatment M12/122/124 Primary/Secondary dx OR any other place on the comprehensive assessment ( regardless of whether the diagnosis is documented elsewhere in the OASIS assessment). Clinician will select Response options, 1, or 2 Select NA if the patient does not have a diagnosis of heart failure AT ALL. Consider M15 Symptoms in Heart Failure Patients New or ongoing heart failure symptoms since previous OASIS Review clinical record physical assessment data weight trends clinical notes Dyspnea is a symptom of heart failure and while it may also be a symptom of another co-existing disease process, such as pneumonia, it would still be reported in M15 and M151, Heart Failure Follow-up, if the patient has a diagnosis of heart failure. M151 Heart Failure Follow- up M151 Heart Failure Follow- up Process Outcome NQF endorsed Timepoints Transfer Discharge Include any actions that were taken at least one time at the time of the last OASIS assessment or since that time. Response - No action taken n Interventions are not completed as outlined in this item n Document the rationale in clinical record If Response is selected, none of the other responses should be selected. 213, Selman-Holman & Associates, LLC 4

41 Same Day? When completing M151 - Heart Failure Follow-up, Response 1 is an appropriate response only if a physician responds to the agency communication with acknowledgment of receipt of information and/or further advice or instructions on the same day. Same day in this item means by the end of this same day, and is not the same as "within one calendar day", which is defined in M22, Medication Follow-up as "until the end of the next calendar day". 4b-Q116.2 What if we left a message for the physician on the same day and the physician calls the patient on the same day but not us?? Response 1 cannot be marked. Has to be communication to the agency. 4b M151 Heart Failure Follow- up Response 3 Either the home care clinician reminds the patient to implement physician-established parameters for treatment or is aware that the patient is following physicianestablished parameters for treatment, e.g., took extra diuretic 4b-Q Telehealth and interventions by telephone do count. Therapists providing written materials without assessment of understanding is not an educational intervention. 4b-Q Quiz Example of Not Assessed At recertification, because of exacerbations of other diagnoses, CHF is listed 7 th in the diagnoses. Halfway through the episode the CHF exacerbates and the agency has to intervene. What is the answer to M15 at transfer? X 164 Patient returns from hospital after fracture to hip. First 2 visits by therapist and care is directed to fracture. Patient returns to hospital with heart failure symptoms without being assessed. M15 2 Not assessed M151 No action taken 4b-Q , Selman-Holman & Associates, LLC 41

42 M15; M151 The nurse is notified by family that her patient, who has a diagnosis of heart failure, was admitted to the hospital due to increased shortness of breath due to CHF. The patient had not exhibited s/s of heart failure since SOC. Since the family chose not to call the agency, no visit was made to assess the patient for s/s of CHF on the day he went in the hospital. How do we answer M15, Heart Failure Symptoms and M151, Heart Failure Followup in this situation? M15; M151 1-Yes is the appropriate response if the patient had a diagnosis of heart failure and exhibited symptoms of heart failure at or since the previous OASIS assessment. In your scenario, the patient had a diagnosis of heart failure and the record review revealed that the patient experienced SOB which resulted in a qualifying x hospitalization since the previous OASIS assessment. When completing the Transfer OASIS, the clinician would answer M15 1-Yes, even though the agency did not have the opportunity to assess the symptoms during a visit. 4b-Q b-Q x 168 Elimination Status M16s When answering M151, Heart Failure Follow-up, you report the actions your agency took in response to the heart failure symptoms and if none were taken, Response -No action taken would be appropriate. Include an explanation of the "No" in the clinical record. 4b-Q , Selman-Holman & Associates, LLC 42

43 M16 UTI in the past 14 days? M16 Has this patient been treated for a Urinary Tract Infection in the past 14 days? v Timepoints SOC ROC Discharge v Response -No v Patient has not been treated for a UTI within the past two weeks v Patient may have had symptoms of a UTI or a positive culture for which the physician did not prescribe treatment v Or treatment ended more than 14 days ago M16 Has this patient been treated for a Urinary Tract Infection in the past 14 days? Response 1-Yes Patient has been prescribed an antibiotic within the past 14 days specifically for a confirmed or suspected UTI. Patient is on prophylactic treatment and develops a UTI. Response NA Patient is on prophylactic treatment to prevent UTIs. UK not an option at discharge M16 My patient has an order for Sulfa BID x5 days, during the first five days of every month. Upon my SOC assessment on 11/1, the patient complained of s/s of UTI. The physician was notified, but no order was obtained for a urinalysis since the patient was just beginning her prophylactic treatment that day. How should I answer M16? If the patient was on antibiotics and developed a UTI, the answer would be Yes. The physician must diagnose a UTI to answer yes so the answer is NA. 4b-Q , Selman-Holman & Associates, LLC 43

44 M161 Urinary Incontinence or Urinary Catheter Presence M161 Urinary Incontinence or Urinary Catheter Presence Timepoints SOC/ROC/DC Response -No incontinence or anuria Patient has anuria or an ostomy for urinary drainage (e.g., an ileal conduit) Patient has a urinary diversion that is pouched (ileal conduit, urostomy, ureterostomy, nephrostomy), with or without a stoma M161 Urinary Incontinence or Urinary Catheter Presence v Response 1-Patient is incontinent v If patient is incontinent AT ALL (i.e., occasionally, only when I sneeze, sometimes I leak a little bit, etc.) v Patient is incontinent or is dependent on a timed-voiding program v Timed voiding is defined as scheduled toileting assistance or prompted voiding to manage incontinence based on identified patterns. Time voiding is a compensatory strategy; it does not cure incontinence. M161 Urinary Incontinence or Urinary Catheter Presence v Response 2 Pt requires urinary catheter v Catheter or tube is utilized for drainage (even if catheterizations are intermittent). v Patient requires the use of a urinary catheter for any reason (e.g., retention, postsurgery, incontinence). v Select Response 2 and follow the skip pattern if the patient is both incontinent and requires a urinary catheter. 213, Selman-Holman & Associates, LLC 44

45 M161 Urinary Incontinence or Urinary Catheter Presence M1615 When does Urinary Incontinence Occur? Does the patient admit having difficulty controlling the urine? Do you have orders to change a catheter? Is your stroke patient using an external catheter? Any odors? Consider Physiologic reasons Cognitive impairments Mobility problems M1615 When does Urinary Incontinence occur? Timepoints SOC ROC Discharge Response Timed-voiding defers incontinence Timed voiding determines the patient s pattern for voiding and schedules toileting to prevent episodes of leaking. The patient can self-schedule toileting or the caregiver can prompt or bring the patient to the toilet. Time voiding is a compensatory strategy; it does not cure incontinence. If timed voiding does not defer incontinence, do not select Response. If timed voiding defers incontinence, but there s an occasional accident, up to clinician to determine if in relevant past or if timed voiding is 1% effective. 4b-Q121.1 Response 1 Occasional stress incontinence Patient is unable to prevent escape of relatively small amounts of urine when coughing, sneezing, laughing, lifting, moving from sitting to standing position, or other activities (stress), which increase abdominal pressure. M1615 When does Urinary Incontinence occur? Response 2,3,or 4 Urinary incontinence regularly n Determine when the incontinence usually occurs n May be secondary to a symptom not listed Response 2 During the night only Response 3 During the day only Includes incontinence during daytime naps. Response 4 During the day and night When the patient is incontinent when sleeping at night and up/awake during the day. 213, Selman-Holman & Associates, LLC 45

46 M162 Bowel Incontinence M162 Bowel Incontinence Frequency Timepoints SOC ROC F/U Discharge Response 4 On a daily basis Indicates that the patient experiences bowel incontinence once per day. Response NA Patient has an ostomy for bowel elimination. Unknown Not an option at follow-up or discharge Bowel program no assumed incontinence 4b-Q122 M162 Bowel Incontinence Frequency M163 Ostomy for Bowel Elimination Review the bowel elimination pattern Difficulty controlling stools Diarrhea Note cleanliness Around the toilet Clothing At F/U may ask the aide Consider Physiologic reasons Cognitive impairments Mobility problems 213, Selman-Holman & Associates, LLC 46

47 M163 Ostomy for Bowel Elimination Timepoints SOC ROC FU Addresses bowel ostomies ONLY Applies to any type of ostomy for bowel elimination (e.g., colostomy, ileostomy) If an ostomy has been reversed, then the patient does not have an ostomy at the time of assessment 186 Neuro/Emotional/Behavioral M17s M17 Cognitive Functioning M17 Cognitive Functioning Timepoints SOC ROC Discharge Consider: Patient s signs/symptoms of cognitive dysfunction over the past 24 hours. Amount of supervision and care the patient has required due to cognitive deficits Level of cognitive functioning- including n alertness n orientation n comprehension n concentration n immediate memory for simple commands 213, Selman-Holman & Associates, LLC 47

48 M17 Cognitive Functioning Consider the degree of cognitive dysfunction with Dementia Delirium Development delay disorders Mental Retardation Deficits related to stroke Mood/anxiety disorders Opioid therapy M171 When Confused What if she is confused upon wakening and in new situations? Oct 212 M171 When Confused (Reported or Observed Within the Last 14 Days) Timepoints SOC ROC Discharge May not relate directly to Item M17 Assess specifically for confusion in the past 14 days. If it is reported that the patient is occasionally confused, identify the situation(s) in which confusion has occurred within the last 14 days, if at all. Report any episodes of confusion that occurred during the past 14 days, without regard to the cause of potential relevance of the confusion to this episode of care Nonresponsive means that the patient is unable to respond or the patient responds in a way that you can t make a clinical judgment about the patient s level of orientation. Examples at 4b-Q More Guidance on Selecting Response Response 1 is selected when the patient's confusion is isolated to a new or a complex situation, e.g. the patient became confused when a new caregiver was introduced or when a complicated procedure was taught for the first time. Response 2, 3, & 4 are selected when confusion occurs without the stimulus of a new or complex situation, or when confusion which initially presented with a new or complex situation persists days after the new or complex situation become more routine. Responses 2, 3 & 4 differ from each other based on the time when the confusion occurred. Response 2 is selected if the confusion only occurred when the patient was awakening from a sleep or during the night. Response 3 is selected if the confusion occurs during the day and evening, but is not constant. If confusion was not constant, but occurred more often than just upon awakening or at night, select Response , Selman-Holman & Associates, LLC 48

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