Medical Records Rundown Blog Series Part 4

Click for part 1, part 2, and part 3.

Now that you have obtained your surgery center patient consent form for procedure and anesthesia, there is the pre-anesthetic evaluation, nursing pre-operative assessment, physician pre-operative orders process and the patient belongings checklist to review with the patient provided that you do not have a locker that the patient can place their belongings.   If you have not performed a history and physical on the patient within thirty days of the procedure, it can be done during the pre-operative assessment by a licensed practitioner per CMS Interpretive Guidelines.  Most anesthesia providers perform a history and physical procedure day to ensure no changes in the previous H & P.   Surgeons will also order a HCG pregnancy test on any woman of child-bearing age.  Pregnancy test can also be performed at the contracted lab and results faxed to the surgery center day of procedure.  If you do decide to provide HCG pregnancy test at your center ensure that you have a CLIA waiver and make sure that the manufacturer of the test ensures that it is CLIA approved.  Also, you must ensure that the proper quality controls are performed on the pregnancy test.  If your patient has been diagnosed with diabetes, you must do a glucose (blood sugar) check.  Ensure your glucometer is CLIA waived, make sure you are documenting the test results and most importantly during surgery center accreditation survey time you must have a log present denoting calibrations performed on your glucometer.        

The next process is the “Time Out” which is mandatory to ensure patient safety.  At time of admitting all patients are asked or should be asked to name and locate the area of procedure (site identification).  This is done during the pre-operative assessment.  Once patient is moved into the operating room for the procedure (Intra-Operative) the surgeon will initiate the “Time Out” procedure.  According to the World Health Organization (WHO) the following should occur:

Confirm medical and clinical staff in operating room have introduce themselves

Surgeon verbally confirms patient, site and procedure

Review patient specific concerns

Has antibiotic prophylaxis been given within the last 60 minutes?

It is always good to document the time the surgeon initiated the “Time Out” in the operating room.  Remember to record the times and names on the Anesthesia record, Intra-operative nursing record and to document the allergies on the anesthesia record.  When documenting allergies don’t forget to include the reactions to the allergies.  

Here’s to your success,


Related Posts