Observation documentation - Revision history

Rossdonaldson1: /* See Also */

2026-03-25T19:09:52Z

Rossdonaldson1: /* Key Documentation Requirements */

2026-03-25T19:09:41Z

Key Documentation Requirements

← Older revision		Revision as of 19:09, 25 March 2026
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	==Key Documentation Requirements==		==Key Documentation Requirements==
	*~~'''~~Time observation began~~'''~~ (specific clock time)		*Time observation began (specific clock time)
	*~~'''~~Clinical rationale~~'''~~ for observation (what are you monitoring/ruling out?)		*Clinical rationale for observation (what are you monitoring/ruling out?)
	*~~'''~~Interval assessments~~'''~~ with documented clinical findings		*Interval assessments with documented clinical findings
	*~~'''~~Time observation ended~~'''~~ (specific clock time)		*Time observation ended (specific clock time)
	*~~'''~~Total observation time~~'''~~ in hours		*Total observation time in hours
	*~~'''~~Disposition decision~~'''~~ — admitted, discharged, or AMA with rationale		*Disposition decision — admitted, discharged, or AMA with rationale
	*The attending physician must document an observation order and an observation note		*The attending physician must document an observation order and an observation note

Rossdonaldson1: /* Background */

2026-03-25T19:09:03Z

Background

← Older revision		Revision as of 19:09, 25 March 2026
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	*Observation is typically authorized for up to 24-48 hours (most payors)		*Observation is typically authorized for up to 24-48 hours (most payors)
	*Proper documentation of observation is essential for reimbursement and to justify the level of care		*Proper documentation of observation is essential for reimbursement and to justify the level of care
	*CMS requires documentation of the ~~'''~~medical necessity~~'''~~ for observation, including the ~~'''~~clinical rationale~~'''~~ for why the patient needs continued monitoring<ref>CMS. Medicare Benefit Policy Manual, Chapter 6: Hospital Services Covered Under Part B. Section 20.6.</ref>		*CMS requires documentation of the medical necessity for observation, including the clinical rationale for why the patient needs continued monitoring<ref>CMS. Medicare Benefit Policy Manual, Chapter 6: Hospital Services Covered Under Part B. Section 20.6.</ref>
	*Observation can be billed concurrently with ED E/M services if the observation begins ~~'''~~after~~'''~~ the ED encounter is complete		*Observation can be billed concurrently with ED E/M services if the observation begins after the ED encounter is complete

	==Indications for Observation==		==Indications for Observation==

Danbot: Major expansion: added Background, Indications for Observation, Key Documentation Requirements, expanded sample documentation (initiation, progress, discharge), documentation pages template

2026-03-24T11:00:47Z

Major expansion: added Background, Indications for Observation, Key Documentation Requirements, expanded sample documentation (initiation, progress, discharge), documentation pages template

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-OBSERVATION REPORT
+==Background==
-The family history of @NAME@ is noncontributory. @NAME@ first seen as document in the chart. Observation began at (time) and was necessary in order to determine (name the rule-out/treatment/diagnosis/mgmt decision). Upon re-evaluation, observation revealed that @NAME@ could be discharged and patient discharged at (time).  Total time of observation = (xxx) hours.
+*Observation status is an outpatient designation for patients who require extended monitoring, evaluation, or treatment beyond a typical ED visit but do not meet criteria for inpatient admission
 ==See Also==
 *[[Documentation for emergency physicians]]
 [[Category:Documentation]]

Rossdonaldson1 at 15:08, 5 April 2017

2017-04-05T15:08:29Z

← Older revision		Revision as of 15:08, 5 April 2017
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	The family history of @NAME@ is noncontributory. @NAME@ first seen as document in the chart. Observation began at (time) and was necessary in order to determine (name the rule-out/treatment/diagnosis/mgmt decision). Upon re-evaluation, observation revealed that @NAME@ could be discharged and patient discharged at (time). Total time of observation = (xxx) hours.		The family history of @NAME@ is noncontributory. @NAME@ first seen as document in the chart. Observation began at (time) and was necessary in order to determine (name the rule-out/treatment/diagnosis/mgmt decision). Upon re-evaluation, observation revealed that @NAME@ could be discharged and patient discharged at (time). Total time of observation = (xxx) hours.

			==See Also==
			*[[Documentation for emergency physicians]]

	[[Category:Documentation]]		[[Category:Documentation]]

Rossdonaldson1 at 14:44, 5 April 2017

2017-04-05T14:44:42Z

← Older revision		Revision as of 14:44, 5 April 2017
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	[[Category:~~Observation~~]]		[[Category:Documentation]]

Rossdonaldson1: Created page with "OBSERVATION REPORT The family history of @NAME@ is noncontributory. @NAME@ first seen as document in the chart. Observation began at (time) and was necessary in order to deter..."

2017-04-05T14:43:43Z

Created page with "OBSERVATION REPORT The family history of @NAME@ is noncontributory. @NAME@ first seen as document in the chart. Observation began at (time) and was necessary in order to deter..."

New page

OBSERVATION REPORT
The family history of @NAME@ is noncontributory. @NAME@ first seen as document in the chart. Observation began at (time) and was necessary in order to determine (name the rule-out/treatment/diagnosis/mgmt decision). Upon re-evaluation, observation revealed that @NAME@ could be discharged and patient discharged at (time). Total time of observation = (xxx) hours.

[[Category:Observation]]

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	==See Also==		==See Also==
	*[[Documentation for emergency physicians]]
	*[[Critical care documentation]]
	*[[Billing]]
	*[[Discharge documentation]]

	{{Documentation pages}}		{{Documentation pages}}