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Understand and comply with IM.6.30

HIM Connection, February 17, 2005

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What does IM.6.30 mean?
IM.6.30 addresses record content requirements for operative or other procedures and moderate or deep sedation or anesthesia. The following eight elements of performance all require measures of success for action plans associated with noncompliance.

1. The organization requires a provisional diagnosis in the medical record prior to performing surgery/invasive procedure. This is scored as category C.
2. The organization requires that operative progress notes are entered into the medical record immediately following a procedure. This is scored as category C.
3. When operative reports are dictated or written immediately after each procedure, they are made available as soon as possible and include information, if applicable, on the name of the surgeon, assistant surgeon, procedure performed, findings, specimens removed and sent to pathology, approximate blood loss, post-procedure diagnosis, and the authentication by the surgeon. This is also scored as category C.
4. Post-procedure documentation chronicles vital signs, levels of consciousness, medications administered, IV fluids, any blood components received, complications, and the management of complications. This is also scored as category C.
5. Medical records should demonstrate that post-procedure patients are discharged from the PACU or post-sedation area by a licensed practitioner or by approved discharge criteria. This is also scored as category C.
6. Medical records demonstrate that discharged patients met the approved discharge criteria. This is scored as category B.
7. Medical records include the name of the licensed independent practitioner responsible for discharge. This is scored as category C.

How to comply with the standard
Although the standard doesn't require a policy, many organizations have developed policies for post-procedure notes and use of discharge criteria.

Examples of compliance include using a pre-procedure checklist to ensure that a provisional diagnosis is present 100% of the time. A form is used to facilitate the post-procedure progress note. The form calls for the same elements that will be used in the post-procedure report. Providing the form ensures a complete progress note with information needed to care for the patient. It is important to note that the post-procedure note is always required regardless of the status of the operative report.

The medical executive committee, based on the recommendation of the surgical committee, may approve criteria for discharge from the PACU and the post-sedation area. Physicians routinely write orders to allow discharge when criteria are met. Nurses enter scores for each parameter and patients aren't discharged until they meet appropriate scores.

This excerpt is adapted from the book Information Management: The Compliance Guide to the JCAHO Standards, Fourth Edition.

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