Orders

[Bjones83]

I have orders for observation and the patient stayed long enough to roll to acute. Do I need new orders or is the doctors visit note enough? I am new to chart auditing. Thank you

 

[thomas7331]

I'm not familiar with the terminology you're using here in saying 'stayed long enough to roll to acute'. Do you mean that the patient stayed in observation more than 48 hours or stayed past two midnights? The amount of time the patient stays makes no difference - the status of the patient is the same until the physician writes an order to change the status. If the physician did not sign an order to admit the patient to inpatient status, then the patient remains in observation, regardless of how long they stayed.