If a PA or NP assists in surgery, can they write the immediate post-op notes? In addition, if they can write it, do the post-op notes have to be signed by the surgeon before we move to the next level of care?
Can a PA/NP Write Immediate Post-op Notes?
The TJC standard (RC.02.01.03, EP 5) requires a note to be written upon completion of the surgery/procedure and before the patient is transferred to the next level of care. A resident or PA who may have assisted in the procedure does NOT qualify as the responsible surgeon. They may write and sign the immediate post-op note, but the responsible surgeon must co-sign the note before the patient is moved to the next level of care.
Patton Healthcare Consulting
Patton Healthcare Consulting provides a complete range of Joint Commission and CMS Compliance Assistance and a full range of pre-survey and post survey services.
We serve more than 350 hospitals, behavioral health care organizations, ambulatory clinics and home care companies nationwide—hospitals ranging from critical access hospitals to the largest health systems. Contact us at (888) PHC-INC1 for more information.
Leave a Reply