provider documentation for observation status

What do you require your providers to document for patient's in the
hospital who are discharged in observation status. Our Medical Staff
Rules and Regs require 1) condition of the patient at discharge, 2)
instructions to the patient and final diagnosis. I really couldn't find
anything standard or regulatory guidance on this subject.

Thanks for your feedback.

Marcia Matthias, MJ, RHIA, CHPC
Corporate Director Health Information
Privacy Officer
Southern Illinois Healthcare
Carbondale, IL


  • edited May 2016
    We require the discharge diagnosis on the facesheet.
  • edited May 2016
    No discharge summary is required for observation patients. Discharge instructions are given by nursing and documentation of such is in the chart. Signs and symptoms can be coded, if no definitive diagnosis is reached.

    Sheila Schultz
    Director of HIM
    Wheeling Hospital
    One Medical Park
    Wheeling WV 26003
    Fax 304-243-8599
  • edited May 2016
    We currently don't require a discharge summary, only a final progress note, on observation patients. But, we have created a new policy that would require a discharge summary for observation patients and it is being reviewed by the site Medical Staff Executive Committees. Most sites are accepting of this.

    Pat Gastonguay, MBA, RHIA
    System Director, Health Information Management
    Fairview Health Services
    2450 Riverside Avenue
    Minneapolis, MN 55454
  • edited May 2016
    We do require a history and physical but do not require a discharge summary. Provider must have daily progress notes.

    Catherine S. Kadry, RHIT, CCS, CHA
    Director, Health Information Management
    Pioneers Memorial Healthcare District
    207 W. Legion Road
    Brawley, CA 92227
    Phone (760) 351-3148 Fax (760) 351-3154
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