Standards Q&A: Documenting Nonemergent Health Care Requests

Q: What specific touchpoints should we document for clinical nonemergent medical, dental, and mental health care requests?

A: Per Standard E-07 Nonemergency Health Care Requests and Services, all aspects of the health care request process, from review and prioritization to subsequent encounter, must be documented, dated, and timed. Specific documentation of the following date and time stamps are required:

• Date and time the nonemergent health care request is received by health staff
• Date and time the nonemergent health care request is reviewed and prioritized by qualified health care professional
• Date and time the face-to-face encounter by a qualified health care professional is completed for all clinically based requests

Depending on the facility’s procedures, these three things may occur simultaneously or within minutes, but each component of the process should be documented. For example, in some facilities nurses collect and read paper health care requests right after med pass and then meet with the patient at that time. In others, night shift nurses collect requests, and the face-to-face encounters occur the next day with day shift nursing staff. Regardless of the process, the dates and times of these three aspects should be documented in the health record.

Wendy Habert, MBA, CCHP, is director of NCCHC’s accreditation program. Send your standards-related questions to [email protected].