Wiki H&P for observation charts

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semillhouse

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I'm having trouble finding the answer to a question I have concerning what is required on an outpatient observation chart. I'm wondering if anyone knows if you have to have an H&P, discharge summary, etc and can find anything written to back it up. I've looked everywhere and I can't find a definitive answer. Any help would be greatly appreciated. Thank you!
 
We use these guidelines: If the pt is in an Observation status and gets admitted and Discharge the same day, it is 99234-99236. If the pt stays overnight, you don't use the 99234-99236 but code the intial Observation H&P as 99218-99220, then subsequent days gets 99224-99226. The discharge day gets 99217 as long as it is not the same day as the admission or a subsequent day. The guidelines are listed just before the code 99218. Hope all this helps, Pam
 
I didn't actually mean how would you code an observation visit. I'm more asking about when the actual charts are put together and what information needs to be included on it. Thank you for your reply though
 
Observation

I would also look at progress notes, consults, procedures and, if you use Epic, SnapShot.
 
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