Wiki Inpatient Admission Documentation Requirements

[MWathen]

I have a physician stating that the documentation does not require a remark stating the patient was admitted. (IE: I am admitting John Doe today due to his high blood pressure) My understanding that this should be included in the documentation but I am unable to find any guidelines stating so. Looking for any information available for guidance.

Thank you

 

[Chelle-Lynn]

Here is a link to a really good article that reviews CMS guidelines for admittance and documentation requirements.

https://www.healthlawdiagnosis.com/...t-admission-order-documentation-requirements/

As well as a link to the Admission Order and Certification requirements for CMS:

https://www.cms.gov/Medicare/Medica...loads/IP-Certification-and-Order-09-05-13.pdf