24 Hour Observation Unit & Charting

My unit is in the process of starting an observation unit. It will be detached from the ED, under our Internal Medicine service, catering to CP r/o MI, COPD, CHF, Cellulitis, Syncope and Pneumonia observation status patients. Obs is based around CMS guidelines regarding outpatient treatment, where the patient is a little too sick to go home, but not really sick enough to be admitted as an inpatient. Goal is a less than 24 hour stay, but CMS allows up to 48 hours of observation status.

A couple of questions for those out there dealing with this kind of unit.

1. Charting. According to our understanding of the CMS rules, we have to be "doing" something for the patient to be there, documented every hour. A good example to me is the patient who is waiting on cardiac enzymes to either rule out, or rule in. How/what do y'all chart about these patients during this time frame? Simple focused assessments and/or vitals every hour? Or some variation thereof?

2. Discharge. Is discharge protocol and nurse driven, or are the physicians still intimately involved?

3. Testing. Echos? Stress tests? Ultrasounds? How involved are y'all getting?

Any other information about what has/hasn't worked would be appreciated as well.

Thanks for reading and sharing!

Tom