Reader Question: Registered Nurses

Question: What documentation standards will registered nurses be expected to provide to support levels of service?

Illinois Subscriber

Answer: Each facility is expected to develop and follow its specific criteria. Although there is no nationally accepted standard for nursing documentation to support APC coding, nurses would be expected to provide assessment notes for each patient consistent with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and nursing specialty standards.The book 2000 Hospital Accreditation Standards may be ordered from JCAHO by calling (630) 792-5800. Many medical libraries have this book.

At the same time, nurses must ensure that any service performed and billed with the HCPCS codes is legibly documented and supports medical necessity on the patients medical record.


- Published on 2000-09-01