Post-operative notes

[sbmed100]

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Quick question for y'all...

What is the CMS/JCAHO requirement for post-op notes (I'm in private practice with no residents.) I know the requirement that they have to contain vital signs, mental status, participation in eval, resp status, cv status, level of pain, and nausea status....but I was under the impression a post-op note only had to be done for patients who stayed in the hospital greater than 23 hours. Others in my group state every patient who has received an anesthetic, regardless whether or not they are admitted, has to have a post-op note. Thoughts?

 

[hoyden]

We have a portion in our charts where the postoperative info is printed - you have to check the needed boxes and fill the VS.
Since the newest regulations indeed do require a post-op note on everybody, but do not specify the time frame the earliest the note can be written ( as long as the pt is alert/awake) we just put post op note 3-5 minutes after the finish of the PACU time ( which is 10 minutes from the PACU arrival).

 

[urge]

Others in my group state every patient who has received an anesthetic, regardless whether or not they are admitted, has to have a post-op note. Thoughts?

This

 

[periopdoc]

Others in my group state every patient who has received an anesthetic, regardless whether or not they are admitted, has to have a post-op note. Thoughts?

This

+1

CMS Regulations for an anesthesia post-op note

482.52(b)(3) - A post-anesthesia evaluation completed and documented by an individual qualified to administer anesthesia, as specified in paragraph (a) of this section, no later than 48 hours after surgery or a procedure requiring anesthesia services. The post-anesthesia evaluation for anesthesia recovery must be completed in accordance with State law and with hospital policies and procedures that have been approved by the medical staff and that reflect current standards of anesthesia care.

The post op anesthesia evaluation is required any time general, regional, or monitored anesthesia has been administered to the patient. The American Society of Anesthesiology (ASA) guidelines do not define moderate or conscious sedation as anesthesia. While current practice dictates that the patient receiving conscious sedation be monitored and evaluated before, during, and after the procedure by trained practitioners, a post-anesthesia evaluation is not required (71 FR 68691)
The evaluation must be completed and documented by any practitioner who is qualified to administer anesthesia. In accordance with §482.52(a), anesthesia must be administered only by:

• A qualified anesthesiologist
• A doctor of medicine or osteopathy (other than an anesthesiologist)
• A dentist, oral surgeon or podiatrist who is qualifies to administer anesthesia under State law
• A certified registered nurse anesthetist (CRNA) who, unless exempted in accordance with paragraph (c) of this section, is under the supervision of the operating practitioner or of an anesthesiologist who is immediately available if needed; or
• An anesthesiologist's assistant who is under the supervision of an anesthesiologist who is immediately available if needed

CMS advises Hospitals to consult recognized guidelines when developing policies and procedures for post-anesthesia care. For example the Practice Guidelines for Post-anesthetic Care, Anesthesiology, Vol. 96, No 3, March, 2002, provides the recommendations of the American Society of Anesthesiologists for routine post-anesthesia assessment and monitoring, including monitoring/assessment of:

• Respiratory function, including respiratory rate, airway patency, and oxygen saturation
• Cardiovascular function, including pulse rate and blood pressure
• Mental status
• Temperature
• Pain
• Nausea and vomiting; and Postoperative hydration
• Depending on the specific surgery or procedure performed, additional types of monitoring and assessment may be necessary.

Our postop assessment is completed in the PACU prior to discharge from the PACU. We have a small section of our anesthetic record dedicated to the postop assessment.

- pod

 

[Gasworks]

Does a simple "VSS / No Complications / Stable for discharge" suffice?

 

[Sergio99]

Does a simple "VSS / No Complications / Stable for discharge" suffice?

We have been doing that with checkboxes for several years now and passed all inspections in flying colors.

We have a rule that recovery room nurses cannot discharge any patients unless these areas are filled and signed. As long as the recovery is uneventful and straightforward, we sign each others' patients. If there is no one free to do that, the nurses bring or send the records to us in the operating room to sign. We have 100% compliance.