Post op notes

[risnwb]

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Curious how everyone handles this, especially for small pp groups. Do you assign someone to post op the in-patients from the previous day? Do you do them all yourself? What about your out patient procedures? Does the anesthesiologist running the board for the day sign every single patient out prior to discharge?
Also curious about follow up for nerve blocks?


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[fakin' the funk]

Curious how everyone handles this, especially for small pp groups. Do you assign someone to post op the in-patients from the previous day? Do you do them all yourself? What about your out patient procedures? Does the anesthesiologist running the board for the day sign every single patient out prior to discharge?
Also curious about follow up for nerve blocks?

We do none of that routinely.

 

[caligas]

Post op note in PACU.

 

[fakin' the funk]

We do none of that routinely.

After the immediate post-op note, of course.

 

[risnwb]

So in residency I was told there was some requirement for a note following recovery from anesthesia within 48 hours. I remember something about being docked some unknown amount of money if there were ever an audit or something. Any truth to this?


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[IlDestriero]

We write a post op note prior to discharge from the PACU or upon arrival in the ICU. The NPs look at all the admitted patients the next day.


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Il Destriero

 

[urge]

So in residency I was told there was some requirement for a note following recovery from anesthesia within 48 hours. I remember something about being docked some unknown amount of money if there were ever an audit or something. Any truth to this?


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As far as I know, the anesthesia fee includes a pre op evaluation and a post op check. Nobody cares when you send the bills to collection, but if you ever get audited years later, even by JACO and let alone CMS, you will be in trouble.

 

[neuroride]

Our call guy for the day slips up and visits duramorph c/s patients, postop block pt and then any surgical epidurals running. We write a postop note quick in EMR and send out copy for billing postop visit

 

[deleted50478]

So in residency I was told there was some requirement for a note following recovery from anesthesia within 48 hours. I remember something about being docked some unknown amount of money if there were ever an audit or something. Any truth to this?


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It's easier to do it 15-30 minutes after surgery so people don't fall through the cracks. By all means visit them the next day, but getting the paperwork finished earlier is a good idea I think.

 

[leaverus]

I think most people in my group write theirs immediately in pacu. I do mine from home on the computer - this should be easy to do for most people these days; admittedly not ALL of my (in)patients necessarily get seen in person the next day.

 

[chfo]

For ambulatory patients, I visit them at their home then dictate a note.

 

[Planktonmd]

For ambulatory patients, I visit them at their home then dictate a note.

I bet you this is going to be part of the ASA's surgical home initiative!

 

[ranvier]

For ambulatory patients, I visit them at their home then dictate a note.

we drive them home and then bring them groceries the next day

 

[Psai]

we drive them home and then bring them groceries the next day

Gotta get that satisfaction money

 

[Gas]

We send a CRNA to see all the in-house patients the next day, and for outpatients the anesthesiologist in charge signs off on the charts. That happens sometimes before the patient leaves PACU, but also sometimes after.

I was wondering if anyone documents whether the patient is monitored postoperatively on the postop sheet? I have heard this is a JCAHO and/or CMS requirement, but can't seem to find it anywhere. For example, if I send a morbidly obese OSA patient to the floor on continuous pulse ox for the night, is it a JCAHO or CMS requirement to document that on the sheet?