About the Author:
Mark Aquino is a registered nurse in California with a Bachelors of Science in Nursing and Masters of Health Administration from West Coast University. He has at least 5 years of experience in the front lines as a visiting nurse in home health and hospice in direct patient care. He is author of OASIS NINJA: A Home Health Nurse’s Guide to Visits, Documentation, and Positive Patient Outcomes. This guide provides nurses with the information they need to provide quality care to their patients in the comfort of their own homes. He also writes books about how to live a good life and how to improve yourself on a daily basis such as Self Help Transformation: An Evidence-Based Approach to Personal Transformation for Mental Health, Physical Fitness, Relationships, and Career. You can also find all his books here. Learn more at OasisNinja.com.
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Below is a sample checklist in SOAP format for gathering OASIS data that I personally use which I have customized for my needs. I bring this checklist with me every patient visit and go through this checklist every time so that I do not miss anything.
According to the book Checklist Manifesto: How to Get Things Right by Atul Gawande, checklists are great for improving job performance in the workplace. In my personal experience, having a comprehensive checklist puts me at ease and reduces my anxiety knowing that I have a reference and guide to all things I need to cover during the day.
But be warned that as you go through the process of referencing your checklist day to day, you may notice that after a few weeks or after a few months of using the checklist daily, you start getting into a habit and the checklist starts becoming a mental checklist for you.
Be careful when the physical checklist starts becoming a mental checklist, so that you do not become prideful and start making mistakes. Relying on a mental checklist is a recipe for disaster, as the human mind is prone to error. Always rely on a physical copy of a checklist, whether on paper or digitally, to do your job right.
Let this template be a guide for you to create your own checklist as you see fit, or use this checklist as is for your own practice.
Comprehensive SOC Checklist:
| Patient Name: Date: MD/DO: Reason for Visit: SOC, ROC, Recert, F/U, DC | |
S | From: Community/Hospital/SNF DC Date: LOS: Reason for referral (CC):PMHx: PSHx:HPI (OLDCART): Diabetes, PAD, or PVD?IV Access Y/N Oral: indep/setup/reminder/unable/NA Injectable: indep/setup/reminder/unable/NAMedications (MED LIST): Drug Issues: Allergies: Limitations: Amputation, Dyspnea, Paralysis, Contracture, Blind, Incontinent, Hearing, Endurance, Speech Lives: Alone, w/Someone, ALF Assistance Available: Around Clock, Day, Night, Short Term, None /// PCG name & contact: Community/Social Screening: Needs resources, Sadness, Suicidal, Suspected Abuse/Neglect For: MSW Needed: Y/NHome Safety: Stairs, No running water; poor lighting, heat, or cool; narrow or obstructed walkways, insects/rodents, no fire safety, cluttered/soiled, Other: O2 Safety Y/N: NA, No Smoking Signs, Smoke inside, Smoke Detectors, Fire Extinguisher, Safe Cylinder Storage, Cords Intact, Evacuation Plan, Cleaning Fluids, No petroleum products, Only water-based lip moisturizers Pain: Code Status: DNR/Full code Adv Directives: Vaccines: Flu, Pneumonia, Shingles, TB |
O | VS: BP: PP: Temp: Resp: O2: Ht: Wt: BS: Labs (if any): HEAD TO TOE ASSESSMENT/REVIEW OF SYSTEMS:Sensory: Eyes/Vision: Poor vision? Y/N Ears: HOH? Y/N Nose: Nasal obstruction? Y/N Neuro: Oriented: Person Place Time, Disoriented, Forgetful, PERRL, Seizures, TremorsPsychosocial: Poor Environment, Poor Coping, Agitated, Depressed, Impaired Decision-Making, Anxiety, Inappropriate Behavior, Irritability PHQ-2: Last two weeks, Little interest or pleasure in doing things? Feeling Down, depressed, or hopelessLungs: SOB, Supplemental O2, O2 Sat, Cough, Auscultation lung fields: Adventitious lung sounds? Y/NCardiac: Chest Pain, Dizziness, Edema, Heart Sounds, Peripheral Pulses, Cap Refill <3, >3 Pacemaker. AICDBowels: Incontinen Freq Ostomy: Dialysis Hemo, Graft/Fistula Site: CVC Site: Peritoneal Signs of infection Y/NNutrition: Dysphagia, Poor Appetite, Wt Loss/Gain: Diet: Adequate Y/N Problems: Throat, Dental, Dentures, Chewing, Other:Urinary: Incontinence, Distention, Burning, Frequency, Dysuria, Retention, Urgency, Urostomy Catheter Last Changed: Cloudy, Odorous, Sediment, Hematuria Genitalia:Skin: Wounds:Diabetes: Insulin, pt/cg draw dose/administer, oral hypoglycemic, pt/cg indep with glucometer, inspect feet Blood Sugar:Other Endocrine: Polyuria, Polydipsia, Polyphagia, Neuropathy, Radiculopathy, Retinopathy // Thyroid Problems:Musculoskeletal: WNL Weakness Amb Difficulty Limited Mobility/ROM Joint Pain/Stiffness Poor Balance Grip Strength R L Bed Bound Chair Bound Contracture Paralysis Has Assistive Device/s:Needs DME:ADL/IADLs: Activities Permitted: Bed Rest Cane Partial Weight Bearing Up as tolerated Walker Crutches Exercise Prescribed Wheelchair Indep at Home Transfer bed<>chair Other:ADLs: Indep/Setup/Assist/Dep/Device Grooming Dress upper Dress Lower Bathing Toilet Transfer Toilet Hygiene Transfers Amb EatingGG Scoring: 6 – Indep 5 – Setup 4 – Sup/touch 3 – Partial/Mod 2 – Substantial/Max 1 – Dep 7 – Refused 9 – NA 10/88 – No attempt enviro/safetyGG Questions: Self Care Eating Oral Hygiene Shower Self Dress Upper Dress Lower Don/Doff FootwearMobility Roll Sit>Lying Lying>Sit Sit>Stand Chair<>Bed Toilet Transfer Car Transfer Walk 10 50 (+2 turns) 150 Steps 1 4 12 Pick up object WC Assist 50 150 (+2 turns) |
| A | Nursing Diagnosis: Possible New Medical Diagnosis (if any):Additional Notes: |
| P | Nursing Intervention: Consents/RS Signed: Y/N HHA Agency contact info given: Y/NDisciplines Needed: PT/OT/ST/SN/MSW, AideNext Physician Visit:Pharmacy name and phone: |
I also use a variation of the above comprehensive checklist which has been further simplified, to include just the basics. This shorter checklist serves as a simpler guide when visiting multiple patients and you have had more experience knowing what data can be gathered easily and which data may need more effort and attention to gather. It also fits into just one page.
Simple Checklist:
| Patient Name: Date: MD/DO: Reason for Visit: SOC, ROC, Recert, F/U, DC | |
S | Recent hospitalization date (if any): Primary Dx: Therapies pt receives at home: (IV, parenteral, NG, GT, O2, etc)Advanced directive – yes, no, DNRPt Living Situation: (alone, w others,)Medications (MED LIST): Allergies: Vaccines: Flu, Pneumonia, Shingles, TBPCG name & contact: |
O | VITALS/PAIN – bp, hr, temp, rr, O2sat, *painHt: Wt: BS: SYSTEMS ASSESSMENT:eyes, ears, noseskin, pressure ulcer, woundslung sounds, SOB, O2DM?, thyroid?Heart sound, rhythm, pulse, edema, pacemakerLast BM, GI probs, foley, ostomy, dialsDiet, weight loss, eating well?LOC, depression screen, sleeping well?Mobility, DME needs, recent falls? |
| A | Significant finding(s) to report: |
| P | Nursing Intervention: Consents/RS Signed: Y/N HHA contact info given: Y/NDisciplines Needed: PT/OT/ST/SN/MSW, AideNext Physician Visit:Pharmacy name and phone: |
Where to Download
To download either of these checklists, go to OasisNinja.com/checklist
About the Author:
Mark Aquino is a registered nurse in California with a Bachelors of Science in Nursing and Masters of Health Administration from West Coast University. He has at least 5 years of experience in the front lines as a visiting nurse in home health and hospice in direct patient care. He is author of OASIS NINJA: A Home Health Nurse’s Guide to Visits, Documentation, and Positive Patient Outcomes. This guide provides nurses with the information they need to provide quality care to their patients in the comfort of their own homes. He also writes books about how to live a good life and how to improve yourself on a daily basis such as Self Help Transformation: An Evidence-Based Approach to Personal Transformation for Mental Health, Physical Fitness, Relationships, and Career. You can also find all his books here. Learn more at OasisNinja.com.
Follow for more:
Email Newsletter – Facebook – Instagram – YouTube – Pinterest – Twitter (X) – TikTok – LinkedIn – Reddit
