Looking for some help regarding admitting orders, both for observation and inpatient. We are a CAH.
Observation specifically -
Patient is seen in the ER. ER provider states: Discharge to observation (date and time) to Dr. X
* once that provider signs off on the ER note - can that be used a written order for admission? or is that only considered as the discharge disposition?
* If the nursing documentation starts at 5:00 but the order isn't entered until 6:00, time still starts at 5?
Admitting orders need to be entered at time of admission, but signed prior to discharge - is that correct?
Does the order need to be in the EHR system as an electronic order or a scanned written order? Or can clinical documentation, as above, be considered?
Please help me settle the debate. I'm fairly confident I know the answers, but I'd like to have some backup as I'm new to my position.
Thank you!
Observation specifically -
Patient is seen in the ER. ER provider states: Discharge to observation (date and time) to Dr. X
* once that provider signs off on the ER note - can that be used a written order for admission? or is that only considered as the discharge disposition?
* If the nursing documentation starts at 5:00 but the order isn't entered until 6:00, time still starts at 5?
Admitting orders need to be entered at time of admission, but signed prior to discharge - is that correct?
Does the order need to be in the EHR system as an electronic order or a scanned written order? Or can clinical documentation, as above, be considered?
Please help me settle the debate. I'm fairly confident I know the answers, but I'd like to have some backup as I'm new to my position.
Thank you!