Health Information Management

Count observation time when the patient is moved to the floor after physician order

APCs Insider, April 13, 2007

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QUESTION: We have come across cases in which the physician performs either a surgery or procedure on a patient, and then the physician places an order to admit the patient into observation. Can the physician place the patient directly into observation without waiting four to six hours, as long as it is medically necessary?

And if so, what type of documentation in the medical records would be required to substantiate this type of action?

ANSWER: That is correct. A patient may qualify for observation post-surgery before a four to six hour period. Documentation would show the unexpected medical problem that occurred, for example, a spike in blood pressure. Documentation usually shows the intervention made during the regular recovery phase to resolve the complication. For example, an IV push of an anti-hypertensive medicine and the nurse documentation of continued elevated blood pressure. Then the physician orders observation.

Observation time begins when the patient is moved to the floor after this physician order to observation. Also, when a patient leaves a recovery area to the floor, the physicians often must re-write orders for the nursing floor. This is additional documentation to support the observation status.

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