AS I SEE IT
to conduct the H&P after the patient has been prepped and brought into the oper- ating or procedure room, since the pur- pose of the H&P is to determine before the surgery whether there is anything in the patient’s overall condition that would affect the conduct of the planned proce- dure, or which may even require cancel- lation of the procedure.
What ASCs Should Watch Out For Accreditation and Medicare survey deficiencies related to the H&P fall primarily into three categories: the H&P does not meet the threshold of “comprehensive,” the H&P is not cur- rent (within 30 days) or there is no H&P at all. If older than 30 days, we have seen physicians do an update note only or change the date of the H&P on the electronic medical records (EMR), which is not correct. We have also seen
should ask the patient whether there have been any changes in the H&P. There should be an indication on the medical record of changes in H&P or no changes in H&P, as appropriate. Findings during an accreditation or Medicare certification survey of a fail- ure to comply with CMS’ H&P require- ments will result in a deficiency citation. Once an ASC receives the deficiency notice, it must prepare, implement and submit a plan of correction to the state health department or accrediting body within a specified timeframe.
anesthesia providers do parts of the H&P, which is fine as long as they also document the pre-anesthesia assess- ment required by CMS separately. An update note should be com- pleted immediately before surgery. On the day of the surgery, the surgeon
Debra Stinchcomb, RN, CASC, is a senior consultant with Progressive Surgical So- lutions in Fayetteville, Arkansas. Write her at
debra@pss4asc.com. Regina Boore, RN, CASC, is the president of Progressive Surgical Solutions. Write her at
regina@pss4asc.com.
ASC FOCUS OCTOBER 2017 |
www.ascfocus.org
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