Health Information Management

Tip of the week: Develop a plan to capture postanesthesia evaluations

HIM Connection, April 29, 2008

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CMS addresses postanesthesia evaluations in section 482.52(b)(3) of the Interpretive Guidelines. Although The Joint Commission doesn’t currently require such an evaluation (See PC.13.40), this shouldn’t preclude HIM directors from adding it to their to-do list, says Patricia Pejakovich, a senior consultant based in Battle Creek, MI, for The Greeley Company, a division of HCPro, Inc., in Marblehead, MA.

“Now that it’s in the Interpretive Guidelines, it will become a bigger deal. I’ve seen Joint Commission surveyors ask about it,” she says.

CMS requires individuals qualified to administer anesthesia to complete and document a postanesthesia evaluation no later than 48 hours after surgery or a procedure requiring anesthesia services. The 48-hour time frame is important because certain complications, such as fever, often don’t occur until at least 24 hours after anesthesia has been administered.

Directors should communicate these requirements to the director of anesthesia, Pejakovich says. Review the schedule of all patients who had surgery with anesthesia the previous day. Designate someone as the postanesthesia provider to see those patients.

“You have to have a process in place. Don’t leave it up to the individual anesthesiologist to go back and follow up with the patient,” she says. “It’s labor intensive and it won’t work.”

Editor’s note: This tip was adapted from the May 2008 issue of Medical Records Briefing. For more information or to purchase a copy of this article for $10, visit http://www.hcpro.com/content/209318.cfm.



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