Anesthesia Documentation

Question:

We are working on anesthesia documentation with anesthesiology department as they are working on correcting a finding around missing post-anesthesia evaluation.  

Currently, anesthesiology has two notes: Anesthesiology Discharge from PACU (post-anesthesia recovery) and Post-Anesthesia Evaluation, and they would like to combine them into one to streamline all post-operative evaluations into one.  

In reading through CMS 482.52 and TJC PC.03.01.07, I do not see where this would be a concern.  What are your thoughts? What is the appropriate anesthesia documentation?

Answer:

We would suggest trying to learn from anesthesia why they have two forms or notes at present. What purpose were they designed to serve?  It is possible it is a timing thing.  In a busy outpatient surgery center, your anesthesia provider may walk the patient from the OR to the PACU.  At that point in time, they do a brief evaluation and hand the patient off to the PACU.  

The full post anesthesia evaluation cannot be completed at that time because the patient is still groggy from anesthesia.  The regulations state that the patient has to be sufficiently awake so that they can participate in the evaluation process.  So, thus, a second ‘full’ post anesthesia assessment is done.

Learn more about the “why” behind this request and the new planned work flow.  If their first note really is on discharge from the PACU and not admit to PACU it is far more likely that one note will work.  Please also confirm that the final note contains all eight elements required by CMS/TJC, which are consistent with the ASA clinical guideline.