News and Views for Healthcare Accreditation Professionals

Archive for August, 2012

Operative Notes and Reports: GET IT RIGHT!

There is still a discrepancy between what Joint Commission requires and what CMS requires for post-operative documentation.  Here are some points to consider:

1.  There are two required documents:  an operative REPORT and a p0st-operative NOTE.  Be sure not to confuse these.

2.  CMS only requires a operative REPORT immediately after surgery.  There is no requirement for a short (brief) post-operative note.  24 hours is not in the CMS COP.  Usually this document is completed by dictation.  When the report returns to the medical record (transcription) and is authenticated is governed by hospital policy

3.  Joint Commission DOES require a short (brief) post-operative note IF there is a delay in getting the operative report ON the medical record.

4.  CMS requires that the operative report be completed IMMEDIATELY after surgery.  Joint Commission (RC.02.01.03 EP 5, note #1) will allow a hospital to define what this time period would be if there is a brief operative note.  Be aware, however, that CMS does not accept this type of delay for the operative report, holding the medical staff to getting it done immediately after surgery.

5.  24 Hours is in NO ONE’S standard.  Immediately means before the patient is transferred to the next level of care (generally PACU to inpatient unit or ICU).  So if a hospital is governed by Part A CMS COP, then they may not use 24 hours for anything.

6.  The brief operative note must contain seven elements that are listed in the TJC standard.  Estimated blood loss must be recorded if there is any.  If there is none, it does not need to appear on the report.