Tip: Nursing documentation requirements for observation services
Case Management Weekly, May 11, 2011
Nursing documentation for observation patients must reflect the assessment and reassessment of patient condition and performance of services ordered by physicians. Usually, vital signs are monitored and various treatments are administered, in addition to diagnostic testing. CMS is silent with respect to specific nursing documentation requirements for patients receiving observation services.
This week’s tip is adapted from Observation Services: A Guide to Compliant Level of Care Determinations published by HCPro, Inc. For more information about this book or to order your copy, visit the HCMarketplace.
Do you have a question about a case management topic? Send it to Associate Editor Ben Amirault at bamirault@hcpro.com. An answer to your question might appear in a future issue of Case Management Weekly.
Related Products
Most Popular
- Articles
-
- Practice the six rights of medication administration
- Don’t forget the three checks in medication administration
- Note similarities and differences between HCPCS, CPT® codes
- Differentiate between types of wound debridement
- OB services: Coding inside and outside of the package
- CMS seeks comment on quality measures
- What to include on the incident report
- Know guidelines and subtle differences in code descriptions for laceration repairs
- What is the difference between an IPA and a medical group?
- Pneumonia with a negative chest x-ray: Clinical diagnoses, physician documentation, and coding guidelines
- E-mailed
-
- EPA announces final rule to set new standards on hazardous waste pharmaceuticals
- Use modifier -59 sparingly when reporting add-on codes
- Joint Commission provides tips for improving handoffs
- HIPAA Q&A: You've got questions. We've got answers!
- HIPAA Q&A: Transporting records to satellite clinic
- HFAP unveils OPPE, FPPE requirements
- For commercial payers, is it necessary to perform a recertification visit within the required five-day window?
- Expirations on standing orders
- Correctly bill ancillary bedside procedures in addition to the room rate
- CMS nixes certification requirement for most inpatient hospital stays
- Searched