Q&A: Outpatient documentation frequency

Wednesday, July 11, 2018

Q: Is there a requirement that OB nurses (or other nurses) must document at least every hour while a patient is in outpatient status?

A: As far as I know, there is not a regulation or statute that demands documentation at any time interval. This is usually dictated by the state nurse practice act, accepted nursing practice, and hospital policy and procedure. The time frame may also depend on the patient's clinical condition as you would document more frequently on a patient who was more acute than one who was less acute.

Note: This question was answered by Denise Williams, COC, senior vice president, revenue integrity services, REVANT Solutions, Trussville, Alabama. This question can be found in the coding and documentation section on the NAHRI Forums where you can find answers to questions on a variety of topics from billing and claims to compliance to reimbursement.