Ambulatory surgery facility review standards

Patients who will be undergoing a surgical procedure must have each of the following standards documented.

Regulating body or organization

Each of the following standards is required by one or more of the following bodies.

  • J = Joint Commission on Ambulatory Healthcare Organizations
  • O = Office of Financial and Insurance Services
  • N = National Committee for Quality Assurance
  • PH = Priority Health
  • S = Ambulatory Care of the American College of Surgeons

Standards

Personal/ biographical data

  • Name (O, N)
  • Address (N)
  • Home telephone number (N)
  • Date of birth or age (O, N)
  • Gender (O)
  • Next of kin/ emergency contact with telephone number (O)
  • Employer (N)
  • Work telephone number (N)
  • Marital status (N)

Clearly identify the patient

Patient name or ID number on each page
(N)

Clearly identify the patient receiving the documented care on each page in the chart.

Medication allergies or NKA
(N, S)

Clearly identify all medication allergies in the patient's record. If no allergies, make sure the chart shows "NKA" (for "no known allergies"). This step helps ensure therapeutically safe and effective prescription medications.

Informed consent
(J, O)

Providers must obtain informed consent of the patient, or if applicable, the patient's representative, before administering anesthesia and or performing surgery.

Medical
(J, O, N, S), family (O) & social (O, N) histories as applicable

Medical, family and social histories provide valuable information for developing a planned course of treatment and care. Make sure the historical information is appropriate for the procedure and patient. Document the history in the patient's medical record before administering anesthesia or performing surgery.

Physical exam
(J, O, N, S)

Thorough physical examinations establish a baseline for providing healthcare. Make sure the physical exam is appropriate for the procedure and the patient. Document the physician exam in the patient's medical record before administering anesthesia or performing surgery.

Progress note/ discharge note / physical exam findings
(O, N, S)

Document the physical exam findings so they can be used to plan a course of treatment and care.

Discharge instructions
(J, O)

Clearly document these instructions to appropriately guide the patient during the post-operative period following discharge.

Physician discharging patient identified
(J, O)

Identify the licensed independent practitioner who has appropriate privileges, is familiar with the patient, and is responsible for the decision to discharge the patient.

All entries are legible

Clearly and legibly write all patient record entries so others can read them.

All entries are dated and signed

Make sure all medical record entries identify the author via handwritten signature, an initialed stamped signature, or a unique electronic identification method.

Dated and signed entries:

  1. Prevent potential confusion should questions arise regarding the authenticity of the documentation in the medical record, and
  2. Validate the information source if it becomes necessary to transfer records. If authors use initials instead of signatures, the office must keep a signature register on file. If the office uses an electronic charting systems, take care to password-protect the electronic signature.

Lab/Radiology/Consult reports present (J),
dated (N),
and signed (N)

The physician should date and sign (or initial) all lab, radiology, and pathology reports to demonstrate timely review. If the physician initials are used instead of signatures, the office must keep a signature register on file. Make sure lab, radiology and pathology documentation is appropriate for the procedure and the patient.

Abnormal results notes/ follow-up plans
(N)

It is essential to take the appropriate actions to address abnormal laboratory, radiology, and or pathology reports.

Operative notes
(J, M, S)

  • Procedure (J, O)
  • Surgeon (J, O)
  • Assistant (J, O)
  • Pre-operative diagnosis (O)
  • Post-operative diagnosis (J, O)
  • Nurse staff (O)
  • Duration of procedure (O)
  • Any unusual problems or occurrences (O)
  • Surgeon's description of tissue removed (J, O)
  • Needle count (S)
  • Dated and signed (N)

Dictate or write the operative notes in the medical record immediately after the surgery. These notes provide an accurate record of the surgical procedure.

Documentation within the operative note should resemble the lay description of the CPT or HCPCS code selected. Notes should clearly support each service performed by describing the approach, anatomical site(s), and surgical techniques used. Documentation for repeated procedures on different anatomical sites (fingers, toes, limbs), spinal levels, or paired organs should clearly detail each distinct procedure and support its medical necessity.

Anesthesia/sedation record

  • Pre-anesthesia evaluation (J)
  • Anesthetic sedation (J, O)
  • Dose of anesthetic sedation (J, O)
  • Duration of anesthetic Ssdation (PH)
  • Procedure (O)
  • Pertinent information related to results or reactions (O)
  • Anesthesiologist / anesthetist (O)
  • Dated and signed (N)

Complete the anesthesia record prior, during and following the procedure to provide an accurate record of the anesthesia administered to the patient.

Nurses' notes

  • Pre-operative vitals (O)
  • Post-operative vitals (O)
  • Relevant observations (O)
  • Patient's condition on discharge (O)
  • Dated (N) and signed (O)

Include vital signs and all pertinent observations relevant to patient and procedure.

Doctor's orders (O)
Dated (N)
Signed (N)

The doctor's orders should be appropriate to the patient's physical exam findings and condition.