Post-ops

[panetrain]

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I don't know about your institution but at mine, the anesthesia post-op note is the only note from any and all medical and surgical services that does not need to be co-signed by an attending? Why is this so?😱

 

[Planktonmd]

I don't know about your institution but at mine, the anesthesia post-op note is the only note from any and all medical and surgical services that does not need to be co-signed by an attending? Why is this so?😱

Because nobody ever reads it?

 

[panetrain]

I would argue that if the attending's signature is not required, then the note is not necessary for all patients. They are a waste of time and man power! How can attendings disagree with me if they refuse to actually evaluate each patient post-operatively for themselves like every other medical professional does?😕 I'm not buying that "post-ops are the resident's job" For fu** sake, evaluate your own patients just like our surgery attendings do if you think this note is so imperative to your overall level of care!

Because nobody ever reads it?

 

[nutmegs]

I would argue that if the attending's signature is not required, then the note is not necessary for all patients. They are a waste of time and man power! How can attendings disagree with me if they refuse to actually evaluate each patient post-operatively for themselves like every other medical professional does?😕 I'm not buying that "post-ops are the resident's job" For fu** sake, evaluate your own patients just like our surgery attendings do if you think this note is so imperative to your overall level of care!

I think it's just required for reimbursement. Just needs to be an MD.

 

[rsgillmd]

I think it's just required for reimbursement. Just needs to be an MD.

Nutmegs is right. From what I was told, Medicare/Medicaid will not reimburse without a post-op note. They may reimburse you initially but if the chart is audited, you will be fined.

I was told any anesthesia resident/attending can sign the note. In my CA-1 year we started doing our post-op notes in the computer, so the attending's name gets selected/typed in. This is in addition to the electronic signature of the person writing the note.

 

[panetrain]

Is this true across the US or does it vary by state? If this is true, then every Medicare/Medicaid patient admitted after surgery in private practice needs a post-op note?

Nutmegs is right. From what I was told, Medicare/Medicaid will not reimburse without a post-op note. They may reimburse you initially but if the chart is audited, you will be fined.

I was told any anesthesia resident/attending can sign the note. In my CA-1 year we started doing our post-op notes in the computer, so the attending's name gets selected/typed in. This is in addition to the electronic signature of the person writing the note.

 

[rsgillmd]

Is this true across the US or does it vary by state? If this is true, then every Medicare/Medicaid patient admitted after surgery in private practice needs a post-op note?

I assume it's true across the U.S.A. because Medicare/Medicaid payments come from the federal government. I'm just quoting what my vice chairman told me and other residents several times. Maybe after I finish my orals next week, I will try to look up a reference.

 

[jetproppilot]

I don't know about your institution but at mine, the anesthesia post-op note is the only note from any and all medical and surgical services that does not need to be co-signed by an attending? Why is this so?😱

I'm trying to figure out the context of your question.

Heres a REAL WORLD NEWSFLASH:

In justabout every hospital I've had the privelege of working in,

THE POST OP NOTE IS A FORMALITY.

Nothing more, nothing less.

Lets not kid ourselves.

I'm priveleged to have PACU nurses that are, collectively, DA BOMB.

If something is wrong post operatively they let me know about it.

More often than not the RNs in the PACU troubleshoot whatever needs to be troubleshooted and I cosign their "voice orders."

 

[DET0897]

Nutmegs is right. From what I was told, Medicare/Medicaid will not reimburse without a post-op note. They may reimburse you initially but if the chart is audited, you will be fined.
.

This is not true. What constitutes Medicare/Medicaid post-op requirements for reimbursement is generally covered during any PACU stay and post-op note is not needed.

 

[Surfer]

This is not true. What constitutes Medicare/Medicaid post-op requirements for reimbursement is generally covered during any PACU stay and post-op note is not needed.

you are correct

 

[periopdoc]

Per CMS Conditions of Participation for Anesthesia Services

482.52(b) - The policies must ensure that the following are provided for each patient:...

482.52(b)(3) - A postanesthesia 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 postanesthesia 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.

Per State Operations Manual: Hospital Interpretive Guidelines and Survey Procedures

§482.52(b)(3)

A postanesthesia evaluation must be completed and documented no later than 48 hours after surgery or a procedure requiring anesthesia services. The evaluation is required any time general, regional, or monitored anesthesia has been administered to the patient. 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 postanesthesia evaluation is not required (71 FR 68691)

The evaluation must be completed and documented by any practitioner who is qualified to administer anesthesia.

This was changed sometime in the last five years to allow for the postoperative visit to be carried out by "any qualified provider" as opposed to "the individual who administers the anesthesia."

As long as some sort of postop note is written by "a qualified provider," the requirement is met, and the note can be written in PACU as long as it is dated/ timed after conclusion of anesthesia care. If only PACU nursing staff are documenting postoperatively then the requirement is not met. I believe that there are four components mandatory in the postop note. Level of consciousness, cardiopulmonary status, presence or absence of postoperative complications, follow-up care or observations needed.

Documentation of the postoperative visit is also an ACGME and JCAHO requirement.

Of course if you never get audited then...

- pod

 

[Surfer]

Per CMS Conditions of Participation for Anesthesia Services



Per State Operations Manual: Hospital Interpretive Guidelines and Survey Procedures




This was changed sometime in the last five years to allow for the postoperative visit to be carried out by "any qualified provider" as opposed to "the individual who administers the anesthesia."

As long as some sort of postop note is written by "a qualified provider," the requirement is met, and the note can be written in PACU as long as it is dated/ timed after conclusion of anesthesia care. If only PACU nursing staff are documenting postoperatively then the requirement is not met. I believe that there are four components mandatory in the postop note. Level of consciousness, cardiopulmonary status, presence or absence of postoperative complications, follow-up care or observations needed.

Documentation of the postoperative visit is also an ACGME and JCAHO requirement.

Of course if you never get audited then...

- pod

yeah but you can do all that in the pacu.

 

[anesthesiadoc]

yeah but you can do all that in the pacu.

no, you can't. the requirement is a post op note after the recovery room. pacu signouts do not count according the joint commission. (we just had a big meeting on this at my hospital)

 

[DET0897]

no, you can't. the requirement is a post op note after the recovery room. pacu signouts do not count according the joint commission. (we just had a big meeting on this at my hospital)

Please show me where the JC says a note is needed after the patient is signed-out of the PACU by a qualified anesthesia provider in order to be compliant with medicare/aid reimbursement. I dont see it in the 2009 publication:

Standard PC.03.01.07
Elements of Performance for PC.03.01.07
For hospitals that use Joint Commission accreditation for deemed status purposes: A post-anesthesia evaluation is completed and
documented by an individual qualified to administer anesthesia no later than 48 hours after surgery or a procedure requiring anesthesia
services.
7.
For hospitals that use Joint Commission accreditation for deemed status purposes: The post-anesthesia evaluation for anesthesia recovery is
completed in accordance with law and regulation and policies and procedures that have been approved by the medical staff.

 

[nutmegs]

This is not true. What constitutes Medicare/Medicaid post-op requirements for reimbursement is generally covered during any PACU stay and post-op note is not needed.

I didn't say it couldn't be done in the PACU. Our documentation is on the back of our PACU order sheet and gets signed (by a "qualified provider") before the patient leaves the PACU. We only have to venture out into the world to write notes on direct ICU transports who never stop in the PACU.

 

[Bertelman]

This all sounds like fiction to me. I've never signed a post-op note, never been asked to write a post-op note, and never seen a post-op note unless there was some event in the PACU.