Critical Care Time Attestation

(Include this attestation only if the patient is critically ill/injured AND total critical care time can be precisely determined; otherwise omit this entire block.)

Date of Service: [calendar date]

Location: [ICU / ED / unit]

Critical Care Time Attestation

Medical Necessity: [Concise statement of why the patient is critically ill or injured, naming the primary critical condition, the organ system(s) failing or at risk, and the nature of imminent or life-threatening deterioration] (Limit to 1–3 sentences.)

Critical Care Services Provided:

[Brief problem-focused narrative summarizing key critical care work: reassessments, data interpretation tied to management decisions, interventions initiated or adjusted, and time-sensitive care coordination] (Use single paragraph format when primarily managing one system.)

(OR use bulleted format below when managing multiple organ systems:)

• [Problem/System 1]: [Targeted assessments, data reviewed and how it changed management, interventions initiated or adjusted, urgent coordination]
• [Problem/System 2]: [As above] (Include additional bullets only as needed.)

Time Statement: I personally provided a total of [integer] minutes of critical care time for this patient during this encounter. This time reflects my full attention devoted to the direct care of this critically ill/injured patient. (Use exact integer; do not use "at least," "approximately," or similar qualifiers.)

Procedure Time Exclusion: [No separately reportable procedures were performed; 0 minutes excluded. / The above time excludes the following separately reportable procedures:]

• [Procedure name]: [integer] minutes excluded
• [Additional procedure]: [integer] minutes excluded (Include only if applicable.)

(If no procedures performed, use the first option and omit the bulleted list.)

Family/Surrogate Discussion: [Participants and relationship to patient] discussed [specific immediate treatment decision required]. Patient could not participate due to [reason for incapacity]. [Integer] minutes of this discussion are included in the total critical care time above. (Include this section only if BOTH: the patient could not meaningfully participate in history or decision-making, AND the discussion was necessary for immediate treatment decisions. If criteria not met, document the conversation elsewhere in the note.)