labor epidural documentation compliance

[caligas]

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Anybody know of any compliance requirements for ongoing documentation of patient assessment for labor epidurals? Can you rely on RN charting of hourly vitals? Thanks for any insight.

 

[leaverus]

Requirements by whom? The government? Never heard of any. Even in residency the only vitals i jotted down were during placement of the epidural and if i came back for re-assessment/re-dose. Don't see why it would be an issue - we send patients to the floor all the time with post-op epidural infusions and rely on nursing vitals then as well.

 

[caligas]

Requirements by whom? The government? Never heard of any. Even in residency the only vitals i jotted down were during placement of the epidural and if i came back for re-assessment/re-dose. Don't see why it would be an issue - we send patients to the floor all the time with post-op epidural infusions and rely on nursing vitals then as well.

I'm taking about CMS compliance which effectively governs all payers. I can't find anything that addresses the issue, there must not be any specific requirements. Thanks.

 

[B-Bone]

depends how you're billing. if you just bill for placement (base units plus time units while you're in the room), you don't need ongoing documentation. You can also bill one unit per hour for the entire time the thing is in, but you then need to document pain scores (I believe every hour). For most groups, it's not worth the extra manpower to see every patient every hour for the extra units. We did do it in residency, but there we had multiple residents/CRNAs to round on the patients hourly.