Observation documentation

Background

• 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
• 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
• CMS requires documentation of the medical necessity for observation, including the clinical rationale for why the patient needs continued monitoring
• Observation can be billed concurrently with ED E/M services if the observation begins after the ED encounter is complete

Indications for Observation

• Chest pain — rule out ACS with serial troponins and observation
• Syncope — cardiac monitoring and workup
• Asthma/COPD — monitoring response to treatment
• Abdominal pain — serial abdominal exams, pending imaging/surgical consultation
• Atrial fibrillation — rate control observation
• Head injury — neurological monitoring in low-risk patients not meeting admission criteria
• Intoxication — monitoring until clinically sober
• Allergic reaction/Anaphylaxis — monitoring for biphasic reaction
• TIA — rapid workup and risk stratification
• Dehydration — IV fluid resuscitation and reassessment

Key Documentation Requirements

• Time observation began (specific clock time)
• Clinical rationale for observation (what are you monitoring/ruling out?)
• Interval assessments with documented clinical findings
• Time observation ended (specific clock time)
• Total observation time in hours
• Disposition decision — admitted, discharged, or AMA with rationale
• The attending physician must document an observation order and an observation note

Sample Documentation

Observation Initiation

Observation status initiated at [TIME]. @NAME@ requires observation in order to [rule out ACS with serial troponins / monitor response to bronchodilator therapy / observe for neurological deterioration / etc.]. The patient does not currently meet criteria for inpatient admission but requires extended monitoring beyond a typical ED visit. Anticipated observation period: ___ hours.

Observation Progress Note

At [TIME], @NAME@ was reassessed. Vital signs: ___. The patient reports [improvement/no change/worsening] of symptoms. Physical exam notable for: ___. [Lab/imaging results if applicable]. Plan: continue observation / discharge / admit.

Observation Discharge

The family history of @NAME@ is noncontributory. @NAME@ first seen as documented in the chart. Observation began at [TIME] and was necessary in order to [rule out ___/ monitor response to treatment / determine disposition]. Serial evaluations during observation demonstrated [clinical improvement / stable condition / resolution of symptoms]. Upon re-evaluation, observation revealed that @NAME@ could be safely discharged. Patient discharged at [TIME]. Total time of observation = ___ hours. Discharge instructions, return precautions, and follow-up plan provided. See Discharge documentation.

See Also

• Documentation for emergency physicians
• Critical care documentation
• Billing
• Discharge documentation

Documentation Pages

• General
  • Documentation for emergency physicians
  • Billing
• Components of the Medical Record
  • Review of systems documentation
  • Physical exam documentation
  • Differential diagnosis documentation
  • MDM for different chief complaints
  • MDM for different chief complaints (peds)
• Procedure and Reexamination
  • Procedure sample documentation
  • Reexamination sample documentation
• Special Documentation
  • Critical care documentation
  • Observation documentation
  • Against medical advice
  • Discharge documentation
  • Death documentation
  • Informed consent documentation
• Reference
  • Ophthalmology abbreviations