Awareness : OBC Tips

Anesthesia Medical Direction Rules

Preoperative Evaluation

The anesthesiologist must document that he/she examined the patient and his/her individual assessment.  One does not need to repeat a previous evaluation and can note the resident’s, CRNA’s, AA’s, or PA’s information, but writing “agree with above” is not sufficient. The anesthesiologist must also document his/her anesthetic care plan.

Example:

  • (for Cholecystectomy) Patient examined. Above noted. 43 yo woman, ASA II for HTN and obesity. Plan GA with ETT.

Intraoperative Presence and Direction

CMS requires documentation of availability throughout the case and presence for critical portions of the anesthesia, including induction and emergence. You can document availability in the anesthesia record with a note, such as “available throughout.”

For documenting intraoperative monitoring of the course of anesthesia, the anesthesiologist should note the time and initial to document his/her presence. This may simply be documentation of “VSS” or may be more detailed if a significant event is occurring.

On the anesthesia record, the documentation should show documentation of induction, emergence, and postoperative notes. Also, additional notes for other events, e.g., transfer of care, intraoperative monitoring, line placements, or other intraoperative events are to be documented. These notes should document the anesthesiologist’s presence and medical direction, but should not include the words “supervise” or “supervised” to avoid confusion.

Examples:

Induction-specific notes:

“Present for induction, …

  • ...Smooth mask induction, IV placed, intubation without problem”
  • ...IV induction, intubation as noted, present for positioning”
  • ...Spinal placed at L2-3 without difficulty”

Emergence-specific notes:

“Present for emergence, ...

  • ... Awake, extubated”
  • ... and extubation”

The medical direction requirement is to provide indicated post-anesthesia care. For a patient with an uncomplicated course, this indicated care might simply entail an examination of the patient in a recovery area and note no apparent anesthetic complications. Similarly, if patient is taken to ICU from the OR, the indicated care may be in the report given to ICU team.

Example:

  • for PACU patient: “Patient examined. Awake. VSS, no apparent complications from anesthesia”
  • for ICU patient: “VSS, Report given to ICU Staff”
  • for ICU patient: “patient ready for transfer, Report given to ICU Staff”