HOSPITAL OQR PROVIDER CONTACT TIME: GUIDELINES
When abstracting door to evaluation times for OP-20 (Door to Diagnostic Evaluation by a Qualified
Medical Professional):

Remember the definition of door to evaluation time:
The time (military time) represented in hours and minutes for the first direct, personal exchange
between an ambulatory patient and a physician or institutionally credentialed provider to initiate
the medical screening examination in the emergency department

There must be documentation of direct contact between the patient and the physician or institutionally
credentialed provider.

The exclusion guidelines for abstraction are provider-assigned time, admission time, arrival time,
presentation time, and triage time.

Do use a Nurses Note stating that there was contact, e.g., “MD in room for exam,” “MD at bedside,” etc.

Do use a Medical Screening Exam (MSE) if it is substantiated by a documented physical exam.

Do not use the time on H&P, history of present illness (HPI), order sheets, or any other physiciangenerated sheet, unless it specifically says that there was direct contact.
Note the following frequently asked questions:
QUES TION : Our event log states: “Seen by Provider at 0800.” Can we use this time?
ANS WER: Yes. The time in the event log may be used as the Provider Contact Time if there is substantiation
that there was an exam, a note, or a comment by the provider in the record.
QUES TION : The provider documents: “Time seen: 0800.” Can we use this time?
ANS WER: The patient’s time alone is not acceptable. If the time the exam was performed was 0800, this
time would be acceptable. “Time seen,” as entered on the event log, must refer to the time of the provider’s
first direct contact with the patient.
QUES TION : What are some of the terms we can use for door to diagnostic evaluation by the
physician/APN/PA or institutionally credentialed provider?
ANSWER: Some acceptable phrases are:
o
o
o
o
o
MD assess date and time
Provider contact time
Patient medically screened
Exam time
Seen by provider
o
o
o
o
o
Provider in room with patient
Resident provider contact
Attending provider contact
Provider first contact
Initial provider contact
QUESTIO N: Am I able to abstract the Provider Contact Time from the event log?
January 2017
Page 1 of 2
ANSWER: The event log time may be abstracted provided that there is supporting documentation in the
medical record that notes the patient was evaluated face-to-face by the provider. The data element specifies
that there must be documentation of contact.
QUESTIO N: The HPI is signed by the physician at 2120. Can I use that as the Provider Contact Time?
ANSWER: No. This time does not indicate when the physician actually saw the patient. He/she could have
begun the note before seeing the patient with information from triage, or she/he could have written it after
the patient went home.
QUESTIO N: Our hospital sends its obstetrics (OB) patients directly from triage to observation to be seen
there. Obstetrics uses a completely different record but uses the same E/M codes as the ED. Should I use
UTD for the Provider Contact Time?
ANSWER: No. You should use the contact time indicated by the provider in OB who saw the patient. This
provider may be an OB nurse who has been approved by the facility as an institutionally credentialed
provider. Your hospital has decided that the OB department (for patients who believe they are in labor but
are not) is an extension of the ED because OB uses the E/M codes, meaning that those codes are to be
included in the ED-Throughput measures.
QUESTIO N: The physician wrote and signed the orders at 1300. Can I use that time as the Provider Contact
Time?
ANSWER: No. The physician could have written some of the orders before seeing the patient after reading or
speaking with triage or the bedside nurse.
January 2017
Page 2 of 2