Volume 2024 | No. 2
SURVEYOR
AMBULATORY SURGERY CENTER
CHAPTER 08: MEDICAL RECORDS 08.00.03 Form and Content of the Medical Record Overview of the requirement:
CHAPTER 05: INFECTION PREVENTION AND CONTROL 05.00.06 Sanitary Environment Overview of the requirement:
Each patient of the ASC has a complete, accurate, and legible medical record that includes defined information. Compliance is assessed through record review. The standard includes a list of eight required elements and citations are noted when any element is missing. A significant number of deficiencies tied to aspects of the discharge process.
All areas and equipment in the ASC must be maintained to avoid sources and transmission of infection. Policies define expectations for specific aspects of environmental cleanliness, and these are based on nationally recognized infection control guidelines. Compliance is evaluated through direct observation and reference to policies. Deficiencies noted were all directly observable and therefore avoidable by an alert, and action-oriented staff.
Comment on deficiencies:
Comment on deficiencies:
Frequency of citation:
51%
Examples of surveyor findings:
n The organization completes all medical record forms on the day of service, at the time of registration. Forms are pre-signed by the provider and indicate no date or time raising concerns about the authentication process. n Five of ten records reviewed included an H&P that was performed more than 30 days prior to the procedure. n Six of 20 records reviewed did not include a pre-surgical assessment. n Records were lacking vital signs within the anesthesia risk evaluation. n A patient with suspected pneumothorax was ordered and sent for a chest x-ray, but no resulting report was included in the record. n Records omitted documentation of a surgical time-out. n Records lacked an OR-to-PACU handoff report. n Closed patient records did not include a discharge order. n Each patient is given a prescription for Zofran PRN on discharge. There is no order for Zofran on the charts. n Records of two patient transferred via ambulance to a hospital emergency department lacked documentation required by the ASC’s policy, “Recognition of Patient Deterioration.” n Discharge instructions state “do not drive any vehicle for the remainder of today,” but patients were allowed to drive themselves home.
Frequency of citation:
38%
Examples of surveyor findings:
n Opened sterile supplies were observed in unused spaces: oxygen masks with tubing packages in three PACU bays; suction tips and NG tube in the anesthesia cart of OR2. n Rust was observed on casters of surgical tables and mayo stands in OR1, 3, 4. n Of 22 pre- and post-op bays, 21 had open suction tubing attached to the suction equipment. The last had tubing still sealed in the wrapper. n One used surgical bunny suit and shoe covers were draped over clean supplies (medications) in the pharmacy receiving and storage room. n Corrosion was visible on scrub sink faucets at the point of water flow. n Dust, dirt, and debris were observed under the sink in pre-op, on top of the warmer, on top of the ice machine, on top of the emergency cart, on the fire alarm system panel obscuring the screen readout. n The integrity of OR floors, walls, and doors was not maintained. n Corrugated boxes are stored with clean patient care supplies and clean linen. n The organization does not have a spill kit as required by OSHA. n After a patient left the pre-op room to go to the OR, the blood pressure cuff, pulse oximeter, EKG leads, cords, and chair were not sanitized before the next patient entered this room. According to facility policy “Patient turn- overs,” all areas that come in contact with patients are to be cleaned with an approved germicidal agent after use, between cases, including but not limited to chairs, B/P cuff, oxygen monitors, EKG leads, and cords. n Train staff to follow your policies as written. n Create infection control quality goals related to environmental conditions. n Conduct regular infection control surveillance rounds for equipment and environmental issues like rust, surface flaws (divots, chips, separations), dust accumulation, etc., to promote a culture of cleanliness. n Establish a schedule for routine cleaning of surfaces, including under sinks, top of warmers, ice machines, and emergency carts.
Medical records support continuity of care. Do not allow goals for efficiency to supersede the importance of complete and accurate records.
Tips for compliance:
Tips for compliance:
n Establish baseline checklists that identify pre-, intra-, and postoperative docu- mentation for patient medical records. n Train staff on policies related to medical records. n Complete and accurate records are critical for continuity of care when an unanticipated patient transfer occurs. Ensure that responsibilities are assigned to team roles within the appropriate scope of practice. n Conduct rando m file audits quarterly or as defined by your policy.
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