OASIS E: Module 8 - Discharge and Transfer Specific Items

Course Learning Outcomes

As a result of participating in this learning activity the learner will be able to:

  • Demonstrate knowledge of how to accurately gather clinically driven patient assessment information and appropriately apply it to OASIS items related to discharge and transfer by passing the final exam with a score of 80% or higher at the end of the on-line learning activity.

The OASIS tool is often viewed as another required document to be completed by healthcare professionals. However, with knowledge and skill, the OASIS can be an important tool in the process of patient assessment data collection, evidence-based care planning, and improving client outcomes. 

This module provides the home care professional with knowledge of appropriate assessment information to gather at the time of discharge or transfer of the client and appropriately apply it to OASIS items.

This is a self-paced course with knowledge check activities. These non-graded activities allow you to check your understanding of the lesson objectives before proceeding on in the course. At the end of the course, you will be required to take the final exam. You must score 80% or higher to pass the course and complete the evaluation to obtain a certificate of completion. The last day to successfully complete this course and receive a Certificate of Completion will be December 31, 2025. You must complete the content, Final Quiz, and Course Survey on or before that day.

  • Refer to guidance regarding the correct use of “Death at Home”
  • Follow agency policies regarding the handoff of a reconciled medication list
  • Conduct a skin assessment as part of an agency discharge visit
  • Assess episode dates in relation to the influenza vaccine specific items
Contact Time

1 Contact Hour: based on 60 minute hour

Estimated Time

The estimated time for completion for this activity is 1 hour(s).

Intended Audience

This course is designed to meet the continuing education requirements of health care professionals such as Registered Nurses, Physical Therapists, Speech Therapists, and Occupational Therapists.

Course Planning Team

Cindy Krafft PT, MS, HCS-O, Kathy L. Richie, RN, BSN

Course Expiration Date

As required by ANCC, this course will be reviewed and updated or discontinued on or before December 15, 2025.

NCPD - Nursing Continuing Professional Development
Rochester Community & Technical College is approved with distinction as a provider of nursing continuing professional development by the Wisconsin Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.
Provider Approval Number: WICEAP-0149-007
HLC - Higher Learning Commission
Rochester Community and Technical College is fully accredited by the Higher Learning Commission of the North Central Association of Colleges and Schools.
HLC Institution ID:1399
Disclosure Statements:

Commercial Support: This course was developed in accordance with ANCC Commercial Support Guidelines. No commercial support was accepted for the development of this course.

Mitigation of Relevant Financial Relationships: No planners or faculty have any financial relationships (with companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients) that are relevant to the content of this educational activity.

Author Originating

Cindy Krafft - PT MS HCS-O

Cindy Krafft brings more than 20 years of home health expertise that ranges from direct patient care to operational and management issues. For the past 15 years, Cindy has been a nationally recognized educator in the areas of documentation, regulation, therapy utilization and OASIS. She has served on several CMS driven Technical Expert Panels as well as an expert resource for OASIS Updates. Her focus is on providing the knowledge and tools to operationalize external requirements while keeping the driver of care where it needs to be – the needs of each patient being cared for in the home setting. Cindy has been involved at the senior leadership level for the Home Health Section of the American Physical Therapy Association for more than 10 years and is the immediate past President of that organization. She has been working with APTA and CMS to clarify regulatory expectations and address proposed payment methodologies to ensure the long term participation of all services provided in the home health setting.


Materials used in connection with this course may be subject to copyright protection. Retention of the materials for longer than the class term, unauthorized further dissemination of the materials, or use of copyrighted materials in any way other than intended for this class is prohibited by Copyright and Teach Act laws.


This course was developed with Rochester Community and Technical College's Continuing Education and Workforce Development Division located in Rochester Minnesota.

Evidence Based References
OASIS E Guidance Manual
October 1 2022 - Pages 261 - 381 - https://www.cms.gov/files/document/oasis-e-guidance-manual51622.pdf
Home Health Quality Reporting Program
October 1 2022 - - https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/index.html
Home Health OASIS July 2022 Quarterly Q&As
October 1 2022 - - https://qtso.cms.gov/system/files/qtso/508_CMS_OAI_2nd_Qtr_2022_QAs_July_2022_final_0.pdf
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