Wiki Observation Documentation

[DonnaKelso]

Looking for clarification, does anyone know the answer. If a patient is in observation for 19 hours how often does an MD have to document on the chart? In my facility there is much debate over this. Any help is welcomed.

Thank You

 

[thomas7331]

I have never heard of a specific requirement for this - I think if there is, it is probably a clinical guideline and not something that most coders would be aware of. My sense is there is likely not a universal guideline for this because observation is a service that is ordered by a physician as part of a care plan, but largely performed by the facility staff. The physician would be personally involved and see the patient and document when it is medically appropriate to do so, but that would vary depending on the case. I imagine if there were such requirements, they would be internal guidelines implemented by specific facilities for quality assurance purposes. But I'll be interested to hear if any facility coders have other input on this.

 

[DonnaKelso]

Thank you very much for your input. Hopefully this will help clear things up.

Donna
COC