Q&A: Documentation requirements for nurses

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 timeframe 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 of revenue integrity services for REVANT Solutions in Trussville, Alabama.

This answer was provided based on limited information. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

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