Case Management

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 An answer to your question might appear in a future issue of Case Management Weekly.

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