documentation on OP

Loisrn3

Can you tell me if there is a requirement that OB nurses (or other nurses) must document at least every hour while a patient is outpatient status?

dwilliamsrsi

As far as I know, there is not a regulation or statute that demands documentation at any time interval. This is usually dictated by the State Nurse Practice Act, accepted nursing practice, and hospital policy and procedure. The time frame may also depend on the patient's clinical condition as you would document more frequently on a patient who was more acute than one who was less acute. (basic nursing practice).

trosi

I was researching this recently at our facility and found a clinical nursing policy that required documentation every 60, 30, or 15 minutes for the laboring mom, depending on the stage of labor they were in.  We wanted to use this policy to encourage the OB staff to document their monitoring vitals/data more frequently, especially for our OP in a bed moms that are being evaluated for labor vs. pre-labor, so that our Evaluation and management charge level would be supported by the records.