( 3) Brief description of the planned procedure( s);
( 4) Planned anesthesia type, including risks, benefits, and alternatives; and
( 5) Re-evaluation must be done immediately prior to moderate or deep sedation use and before anesthesia induction.
2. Post-Anesthesia Assessment. The practitioner who administered the anesthesia must write a post-anesthesia follow-up report within 48 hours after completion of surgery. The report should:
a. b.
Be recorded on the Anesthesia Assessment Form; and
Specifically document the CMS mandated criteria for a postanesthesia assessment along with any intra-operative or postoperative anesthesia complications.
3. Pre-Sedation Assessment. All patients undergoing moderate sedation will have an airway assessment prior to the initiation of moderate sedation.
E. Operative Care of Patients.
1. Immediate Progress Note after Surgery. A physician involved in the operative procedure will write, enter or dictate an operative or high-risk procedure report before the patient is transferred to the next level of care with the following exceptions:
a.
b. if the physician writes or enters an operative or high-risk progress note immediately after the procedure, the full report may be dictated / entered within twenty-four( 24) hours of completing the procedure;
if the Provider who has performed the operation or high-risk procedure accompanies the patient from the operating room to the next unit or area of care, the report or note can be written, entered or dictated in the new unit or area of care. The documented note must include the following elements:
( 1) |
patient’ s name and Hospital identification number; |
( 2) |
date and time of the procedure; |
( 3) |
name of primary surgeon and any assistants; |
( 4) |
post-operative diagnosis; |
( 5) |
procedure performed; |
( 6) |
estimated blood loss; |
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