Page 29 - 2022 Risk Basics - Anesthesiology

SVMIC Risk Basics: Anesthesiology

administration of anesthesia and can participate in the

evaluation). If the patient is otherwise admitted directly to the
intensive care unit, there will not be a PACU or transfer note

from the OR to the PACU or the ICU. Include detailed

documentation of the patient’s status when transferring,
including times and oxygenation status. If the PACU is

bypassed, criteria demonstrating the patient status at transfer
of care should be documented.

It is not the responsibility of the anesthesiologist to document

the patient’s condition throughout the PACU stay or when

leaving the PACU. However, significant or unexpected post-
procedural events/complications known to the

anesthesiologist should be documented. Post-anesthesia
evaluation should include documentation of physiologic

condition and presence/absence of anesthesia-related
complications or complaints. It’s important to use pulse

oximetry postoperatively if you suspect obstructive sleep

apnea (OSA). With these patients, consider the use of regional
analgesic techniques without opioids for the postoperative

period.
12

Centers for Medicare & Medicaid Services (CMS) Conditions
of Participation for Hospitals, Section 482.52(b)(3), requires

completion of the post-anesthesia evaluation by the

anesthesia professional or other qualified anesthesia
practitioner no later than 48 hours after surgery or a

procedure requiring anesthesia services in accordance with

12 https://www.asahq.org/standards-and-guidelines/statement-on-documentation-of-anesthesia-
care

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