Page 30 - Part 1 Anesthesiology Common Risk Issues
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SVMIC Anesthesiology: Common Risk Issues
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 State law and with facility policy.
13
The evaluation is performed and documented by a practitioner
qualified to administer anesthesia only after the patient is
sufficiently recovered from the effects of anesthesia (e.g., able
to answer questions) in the PACU/ICU or in another designated
recovery location.
12 https://www.asahq.org/standards-and-guidelines/statement-on-documentation-of-anesthesia-
care
13 https://www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs/Hospitals.html
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