Volume 2025 | No. 2
SURVEYOR
AMBULATORY SURGERY CENTER
Compliance tips for:
Compliance tips for:
Recovery from anesthesia must be evaluated and documented by a physician or anesthetist. A handoff report is provided at the beginning of the post- anesthesia process by the anesthesia provider to the receiving nurse and documented in the post-anesthesia care record. The patient’s condition is monitored and an evaluation of the recovery from anesthesia is completed and documented prior to discharge. ■ Audit patient records to confirm that all required post-anesthesia documentation is present, timed, and signed. ٝ Confirm that timing makes sense based on when the patient left the OR. ■ Create post-anesthesia care checklists to ensure inclusion of all required elements. ٝ For EMRs, work with your IT team to prevent advancing to discharge documentation if the post-anesthesia evaluation is incomplete.
Appropriate case selection is essential for surgical services provided on an outpatient basis. Because a patient’s health status can change from the time of scheduling to the day of the procedure, a risk assessment immediately prior to surgery ensures that the case remains appropriate for the ASC setting. This presurgical assessment is distinct from the pre-anesthesia assessment. It addresses the patient’s current condition, any comorbidities, and identifies any allergies or sensitivities to drugs and biologicals. The result of the assessment is documented, even if there are no concerns identified. ■ Audit records for inclusion of the presurgical risk assessment.
Nerd Newbies (understand the requirement)
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
■ Develop a checklist that incorporates all required elements. For an EMR, require completion of the presurgical risk assessment to advance through the record.
Nerd Trailblazers (prepare the path for others)
09.03.01 Discharge Order Frequency of the citation: 33%
09.02.02 Post-Anesthesia Evaluation and Care Frequency of the citation: 33%
Overview of the requirement: No patient may be discharged from the ASC without a discharge order signed by the physician who performed the surgery. Comment on deficiencies: Compliance is assessed through review of closed patient records. Deficiencies were cited for missing discharge orders and orders that were incomplete. Often, an untimed or unsigned entry was a factor.
Overview of the requirement: Each patient’s recovery from anesthesia is evaluated by a physician or anesthetist prior to discharge from the ASC. Comment on deficiencies: Compliance is evaluated through document review. Deficiencies resulted from missing elements. Surveyor comments centered on issues related to documentation of times.
Examples of ACHC Surveyor findings:
Examples of ACHC Surveyor findings: ■ Records reviewed lacked evidence of a post-anesthesia evaluation after propofol. ■ Records of post-anesthesia recovery did not document a temperature check.
■ Six of 20 records reviewed lacked a discharge order. ■ The pre-printed order sheet was signed, dated, and timed by the physician but the checkboxes to indicate an order were all empty. ■ The ASC lacks a policy for discharge orders. The clinical director could explain the process used but could not produce a written policy.
■ Records lacked the time that the evaluation was performed. ■ There was no documented handoff report to the PACU nurse.
■ Nine of 20 records included a post-anesthesia evaluation that was signed and timed by the anesthesia provider after the patient was discharged home, making it unclear when the assessment occurred. ■ Two of twenty records contained documentation by the anesthesia provider of a post anesthesia evaluation that occurred one minute after the patient’s documented time leaving the OR.
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