Q: A patient has low rectal cancer. The surgeon performed a robotic lap colon resection. The tissue removed was colon and rectum and 0-rings. The operative report states estimated blood loss (EBL) of 500 cubic centimeters (cc) without transfusion of blood.
However, the anesthesiologist documented an EBL of 1100 cc with the administration of two units of packed red blood cells (PRBC) without additional documentation. An order for the blood could not be found in the medical record. The anesthesiologist was queried for an associated diagnosis based on this documentation resulting in the additional documentation of “2 units PRBC’s transfused for estimated blood loss 1100 during surgery as recorded on the anesthesia record” in a progress note.
I have a few questions about this scenario. Are anesthesia records typically used as order forms in the operative setting? Should we find an order for the blood that was transfused? Does the attending physician, which was the surgeon, also need to document in the operative report that the blood was transfused even though he did not order it? As a CDI specialist, do I have the right to ask for a diagnosis for the 2 units PRBC’s transfused during the procedure?
A: This case is a little tricky. First, I would suggest verifying that both the surgeon and the anesthesiologist are referencing the same patient (the records of one patient could have been crossed with another patient). Perhaps the nursing notes could support the anesthesiologist’s or surgeon’s account as 600 EBL is a large discrepancy. It is important to verify that both providers are providing documentation on the same patient/describing the same event.
The nursing notes can also support the administration of the blood as most hospitals have strict protocols regarding the administration of blood (such as two people verifying the patient’s identification/blood type/etc.) and an increased frequency of vital signs to monitor for potential adverse reactions.
Additionally, hospital blood banks typically closely monitor the use of blood as they must have an order, verification of the patient identification including PRBC blood type, administration times, and beginning/ending vital signs.
It appears that there should be documentation from an additional source to support the administration of blood to this patient even if the order is “missing.” If verification shows that both providers (the surgeon and anesthesiologist) are documenting the same event, you may want to refer this record to your HIM manager and/or compliance department because it is a Joint Commission requirement for surgical patients to have a postoperative note following surgery with EBL. Specifically, the Joint Commission website offers the following frequently asked question (emphasis added):
“Q: In what timeframe must an operative report be dictated and placed in the medical record?
A: The operative report must be written or dictated immediately after an operative or other high risk procedure. An organization's policy, based on state law, would define the timeframe for dictation and placement in the medical record.
The most important issue is that there needs to be enough information in the record immediately after surgery in order to manage the patient throughout the postoperative period. This information could be entered as the operative report or as a hand-written operative progress note.
If the operative report is not placed in the medical record immediately after surgery due to transcription or filing delay, then an operative progress note should be entered in the medical record immediately after surgery to provide pertinent information for anyone required to attend to the patient. This operative progress note should contain at a minimum comparable operative report information. These elements include:
- the name of the primary surgeon and assistants
- procedures performed and description of each procedure findings
- estimated blood loss
- specimens removed
- post operative diagnosis
Immediately after surgery is defined as: ‘upon completion of surgery, before the patient is transferred to the next level of care.’ This is to ensure that pertinent information is available to the next caregiver. In addition if the surgeon accompanies the patient from the operating room to the next unit or area of care, the operative note or progress note can be written in that unit or area of care.”
Regarding the role of the CDI specialist, yes, if you see clinical indicators that a patient experienced acute blood loss anemia (ABLA) that was not incidental to the surgery and required treatment with transfusion, you should query for an applicable diagnosis.
Often ABLA is overlooked by surgeons. It is worth having a conversation with your facility’s surgical teams to learn typical/ expected EBL values associated with common procedures performed at your organization. By knowing what is expected you will be better to identify when the EBL and transfusion is not intrinsic to the procedure leading to an undocumented or “missing” diagnosis, which supports querying for a diagnosis to explain the treatment of transfusion with PRBC.
An anesthesiologist is a treating provider, just like a surgeon, and should be able to place orders like the surgeon. The AHIMA physician query practice brief recommends querying the provider who documented the clinical indicators so it is appropriate to query the anesthesiologist.
However, you may also have to consider physician/provider politics. The surgeon is ultimately responsible for the patient. Additionally, coding guidelines state that if a consulting provider’s documentation (anesthesia) contradicts/conflicts that of the attending physician (surgeon) then the attending physician must be queried regarding the diagnosis (e.g., renal failure vs. renal insufficiency) as they have the final say. However, failure of the attending physician to comment on the condition is not the same as documenting conflicting diagnosis.
In this case, the attending physician wasn’t silent as he/she did document 500 EBL and did not document the transfusion; therefore I think that you must query the surgeon/attending physician to validate the findings/documentation of anesthesia and a possible diagnosis of ABLA.
Editor’s Note: Cheryl Ericson, MS, RN,
CDI Education Director for HCPro, Inc., in Danvers, MA, answered this question. Contact her at firstname.lastname@example.org