Observation Procedure

Below is a series on Best Practices for Medical Scribes on Observation Procedures by Alex Serrano

You can read more of Alex’s scribing observations, best practices, and dissertations on the healthcare industry in our blog section.

When a patient complains of chest pain, one of the most common labs ordered is a troponin test. This lab result will identify the level of specialized cardiac proteins in the blood stream to detect cardiac injury. If the initial lab draw is negative, then the health care provider may request a repeat troponin lab. For scribes, situations like these should trigger alarms because this can satisfy the requirements for a special procedure called “observation status.”

Observation Status

“Observation status” or “obs time” is a term used to describe the status of a patient whose constellation of symptoms do not meet the criteria for acute inpatient admission, but who do require hospitalization for a short period of time (at least 4 hours). In other words, the observation procedure can be used when there is diagnostic uncertainty or therapeutic intensity is unknown. This status allows health care providers to obtain further information on the severity of the patient’s symptoms which will then determine if the patient does require admission or could be treated outpatient.

This procedure is frequently used by ED providers. In these unique cases, the length of time acts as a prominent diagnostic tool, so the duration of time contributes to the way that the provider will be reimbursed for the patient encounter. In the example above, the physician can place the patient in observation time in order to reassess the severity of heart damage, if any, that is causing the chest pain, which can determine whether or not the patient needs admission.

Aside from chest pain, other common examples observed in the ED that can result in observation time are: asthma, abdominal pain, renal calculi, dehydration, syncope, allergic reactions, drug ingestion/overdose, or alcohol intoxication. As a result, it is crucial for scribes to pay close attention in their documentation to identify if any patients can qualify for observation time. In fact, experienced scribes should always be completing the highest level of charting (level 5), and an observation status may not be properly reimbursed unless at least 3 Past Medical, Family, and Social History items are documented.

A suggested template to capture required documentation

• Patient has/has no family history of (xxx).
• Patient first seen at (time).
• Observation began at (time) and was necessary in order to determine (name the rule- out/treatment/diagnosis/management decision).
• Upon re-evaluation, observation revealed that the patient should be (admitted/discharged/ followed up right away).
• Patient discharged at (time), total time of observation (xxx) hours.

A modified template for patients staying past midnight

In the event that the patient stays past midnight during their observation stay (patient seen at 2000 and discharged at 0300), a modified format of the template must be utilized for successful billing, coding, and reimbursement. The major difference is the addition of a physical examination. A suggested template is the following:

• Discharge Note: “During patient’s observation in the ED, (tests/labs/intervention) performed.
• Exam: General: NAD, alert, and awake
• CV: RRR without murmur
• Lungs: CTA bilateral
• Abdomen: Soft, nontender, nondistended
• Patient will follow up with their PMD in 2-3 days.
• Patient instructed to return for worsening symptoms.

About the author:

Alex is a MPH graduate from the University of Southern California with an avid interest in health care and medicine predominantly in the prevention of infectious diseases, exacerbation of chronic disease, and understanding the impact of social determinants of health. Currently an epidemiologist, Alex has several years of experience of being a scribe across a broad variety of specialities including: emergency medicine, orthopedics/sports medicine, addiction medicine, and reconstructive surgery.