Volume 2025 | No. 2
SURVEYOR
AMBULATORY SURGERY CENTER
Compliance tips for:
CHAPTER 08: MEDICAL RECORDS 08.00.03 Form and Content of the Medical Record Frequency of the citation: 63%
The patient record is the story of the case and the care received. A complete and accurate record is essential for planning the procedure, for handoffs, and for postsurgical review. ■ Establish checklists that identify pre-, intra-, and postoperative documentation for patient medical records. ٝ Assign the documentation items to the appropriate discipline. ■ Audit patient records for inclusion of all elements. ■ Use the results of record audits to identify focused training. Does a department or individual need coaching on requirements? ■ Review policies and procedures regularly. An updated workflow can put staff in conflict with the ASC’s policies if they are not revised to reflect changes.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Overview of the requirement: Each patient of the ASC has a complete, accurate, and legible medical record that includes at least eight data points described by the standard. Comment on deficiencies: Surveyors review open and closed medical records. Because of the large number of required elements, this standard is a frequent deficiency year after year. This year, a significant number of deficiencies tied to anesthesia documentation.
Nerd Trailblazers (prepare the path for others)
Examples of ACHC Surveyor findings: ■ Records for anesthesia lacked:
CHAPTER 09: PATIENT ASSESSMENT 09.00.03 Presurgical Risk Assessment Frequency of the citation: 29%
ٝ Evidence of a recovery evaluation by an anesthesia provider (15 of 16 records). ٝ Evidence that the anesthesia machine was checked prior to start of the procedure (16 of 16). ٝ Documentation of the anesthesia machine number associated with the procedure (16 of 16). ■ The intra-operative anesthesia record lacked times that vital signs were obtained and medication administered. ■ Although all records reviewed included a pre-anesthesia assessment, the assessments were not dated or timed, making it unclear when they were performed. ■ Three of ten medical records lacked a discharge order. ٝ Four of ten were missing documentation by a nurse that the patient’s post-op discharge criteria were met. ■ Records lacked a pre-surgical risk assessment. ■ Half the records reviewed included an H&P performed more than 30 days prior to the surgery. ■ Three records noted, “Pt. evaluated by a responsible physician and is ready for discharge.” All three were transferred to the ER. ■ According to facility policy, “The medical record should include: 1. Legible handwriting 2. No empty lines or spaces 3. A discharge diagnosis.” An interview with the PACU RN revealed the post-op diagnosis documentation was removed when they transitioned to using EMR.
Overview of the requirement: Immediately prior to surgery, a physician who will be performing the surgery examines the patient to evaluate the risk of proceeding with the procedure. Comment on deficiencies: Compliance is evaluated through review of patient records. Almost all deficiencies noted missing presurgical risk assessments.
Examples of ACHC Surveyor findings:
■ Records reviewed lacked a presurgical risk assessment. ■ Four of 20 records included a presurgical assessment that lacked a check mark in the box indicating whether the H&P was reviewed and unchanged. ٝ One of 20 contained a pre-surgical risk assessment that was blank. ٝ One of 20 contained a pre-surgical risk assessment that lacked a date and time of completion.
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