Inpatient Facility Coding & Compliance Alert

Question: The nursing staff sometimes documents things on the patient chart that the physician's documentation doesn't note. Are nurse's notes sufficient to satisfy the criteria establishing inpatient status, or are physician notes and diagnostic test results the only elements taken into consideration?

West Virginia Subscriber

Answer: The entire medical record -- including physician notes, nurse notes, and test results -- is reviewed and taken into account when verifying that a patient qualifies for inpatient status. The medical review analyst considers any pre-existing medical conditions and/or extenuating circumstances that make the admission and treatment medically necessary or reasonable.