Quick Reference · 2026

OASIS-E2 Checklist: A Quick Reference for Clinicians & QA Teams

Use this OASIS-E2 checklist before, during, and after every assessment to catch errors early, maximize PDGM accuracy, and stay survey-ready. Print it, post it in the office, or load it on the phone.

📋 Reminder: This is a quick-reference framework. Always reference the official CMS OASIS-E2 Guidance Manual for authoritative item-level guidance. Customize this checklist to match your agency's workflows and EMR.

✅ Before the Visit (Pre-Visit Prep)

  • Review the referral packet, prior assessments, and recent hospital discharge summary
  • Confirm correct OASIS time point (SOC / ROC / Recertification / Transfer / Discharge)
  • Confirm OASIS submission deadline based on time point
  • Verify EMR is on current OASIS-E2 form version
  • Bring required equipment (if any) for in-home functional assessment
  • Review patient-specific items: medications, recent test results, primary diagnosis

✅ During the Visit (Data Collection)

Patient History & Demographics

  • Verify patient demographics, insurance, and Medicare ID
  • Document caregiver presence and support network
  • Confirm current medication list with patient/caregiver

Clinical Items (M-items)

  • Document primary diagnosis and supporting clinical findings
  • Capture all secondary diagnoses (drives PDGM comorbidity adjustment)
  • Document homebound status with specific clinical evidence
  • Document skilled need with specific service justification

Section GG — Functional Assessment

  • Score each GG item using the 6-point scale (Independent → Dependent)
  • Use "activity not attempted" codes correctly when applicable
  • Document Admission Performance, Discharge Goal, and (at discharge) Discharge Performance
  • Verify GG scoring matches narrative description of patient function
  • Confirm functional impairment level (Low / Medium / High) makes clinical sense

Cognitive & Behavioral Items

  • Administer BIMS (Brief Interview for Mental Status) per CMS instructions
  • Administer PHQ-2/9 depression screening per CMS instructions
  • Document behavior frequency and impact items

Social Determinants of Health (SDOH)

  • Ask about housing stability and homelessness risk
  • Screen for food security
  • Assess transportation access
  • Evaluate health literacy
  • Document patient-declined responses with attempts made

✅ After the Visit (Pre-Submission)

  • Cross-check OASIS responses against visit narrative for consistency
  • Verify ICD-10 primary diagnosis aligns with OASIS clinical group
  • Confirm all SDOH items completed (no skipped items without justification)
  • Validate functional impairment level against PDGM payment expectation
  • Check internal item consistency (no logical conflicts)
  • Submit within CMS-required timeframe for the time point

✅ QA Reviewer Checklist

  • Verify time point is correct and submission is within window
  • Confirm primary diagnosis supports OASIS clinical group
  • Validate Section GG functional scoring against narrative
  • Check for SDOH item completeness
  • Verify BIMS / PHQ administered properly
  • Cross-validate medication list and clinical findings
  • Confirm comorbidity adjustment matches secondary diagnoses
  • Document any clinician edits and rationale

Want This Checklist on Autopilot?

Most of these checks happen automatically inside Lime's ambient OASIS-E2 scribe. Real-time QA flags inconsistencies before submission, SDOH prompts ensure no item is skipped, PDGM-aware scoring guidance surfaces functional level shifts, and complete audit logging keeps every assessment survey-ready.

Related OASIS-E2 Resources

OASIS-E2 Checklist — FAQ

What should be on an OASIS-E2 checklist?
An OASIS-E2 checklist should cover the assessment workflow end-to-end: pre-visit preparation, in-visit data collection across all OASIS-E2 item categories (clinical, functional, cognitive, behavioral, SDOH), Section GG functional assessment, ICD-10 coding alignment with the OASIS clinical group, internal consistency checks, and submission timing. The most useful checklists are split by clinician role (assessing clinician vs QA reviewer) and by time point (SOC vs ROC vs Recertification vs Discharge).
How is an OASIS-E2 checklist different from OASIS-E1?
An OASIS-E2 checklist preserves most of the OASIS-E1 workflow but adds checks for refined items — particularly Section GG functional scoring, expanded SDOH items, and updated cognitive/behavioral item administration. Checklists should be re-validated against the CMS OASIS-E2 Guidance Manual at every release update, and reviewed quarterly even when CMS hasn't issued changes.
Can I use this checklist as my agency's OASIS-E2 SOP?
This checklist is a starting framework — agencies should customize it to reflect their specific patient population, EMR system, and QA workflows. Always reference the CMS OASIS-E2 Guidance Manual as the authoritative source for item-level guidance. Have your clinical and compliance leadership review and approve any checklist used as part of your formal OASIS policies and procedures.

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See Lime's OASIS-E2 Scribe