Medical Records Run-down Blog Series Part 2

To continue my series on the medical record rundown, let’s quickly recap the ingredients to an error free medical record thus far by re-reading Part 1.   With each new blog post pertaining to the surgery center medical record rundown I will provide links to all previous Medical Record post. 

Moving on you must obtain a valid consent from the patient to perform the procedure and consent for anesthesia.  The signed consent for the procedure must be obtained prior to the surgical procedure.  It is the physician’s responsibility to discuss with the patient the appropriateness of the proposed procedure, the risks with and without the treatment, the possible need for and the available alternatives, the recovery process, the long-term effects associated with the treatment, and to obtain the patient’s agreement to have the procedure. 

A surgery center nursing staff member will witness the signature on the form and will notify the physician if any misunderstanding is expressed by the patient during the nursing assessment.  The nurse may offer clarification on information given to the patient by the doctor but should not offer new information to the patient.  If the patient’s accompanying adult signed the witness portion of the consent form I encourage also for a member of the nursing staff of the surgery center to sign for the witness as well.  The physician’s name and procedure should always be on the form, this is mandatory.

The informed consent for anesthesia is done prior to the administration of anesthesia by the anesthesia provider in which this person can be a M.D., CRNA, or RN specifically credentialed in the center to provide the type of anesthesia.  If you have a RN in your center credentialed to provide certain types of anesthesia make sure that the RN has been properly credentialed and has been provided competency’s and proctoring.  In some states it is mandatory for physician’s to oversee the administration of anesthesia by a CRNA so verify with your state’s governor to see if that applies. 

The anesthesia provider must inform the patient of the risks, drawbacks, complications and expected effects of anesthesia.  Let your patient know that they are encouraged and have the opportunity to ask questions.  It is the responsibility of the anesthesia provider to obtain this informed consent.  The surgery center nursing staff member is available to witness the document.  As all medical record documents must be signed and dated but this is the start of many in which have to be timed.  I feel that it is the responsibility of the anesthesia provider to time this document after he/she signs it. You can also note the time on the consent for surgery form.   

Once the informed consent for surgery is obtained the surgery nursing staff should just stop and take a few moments to verify that all documents have been signed by the patient including all acknowledgements, consents and all aspects of the surgery have been explained to the patient by the physician and anesthesia provider.  This moment in review will save you a lot of headaches because you will catch it now if you missed a signature by the patient or if the documents are missing the time.

Here’s to your success,



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