( 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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