Anesthesia Post-op Note

What are the CMS requirements for an anesthesia post-op note?

CMS Regulations for an anesthesia post-op note is as follows:

482.52(b)(3) – A post-anesthesia evaluation completed and documented by an individual qualified to administer anesthesia, as specified in paragraph (a) of this section, no later than 48 hours after surgery or a procedure requiring anesthesia services. The post-anesthesia evaluation for anesthesia recovery must be completed in accordance with State law and with hospital policies and procedures that have been approved by the medical staff and that reflect current standards of anesthesia care.

  • The post op anesthesia evaluation is required any time general, regional, or monitored anesthesia has been administered to the patient. The American Society of Anesthesiology (ASA) guidelines do not define moderate or conscious sedation as anesthesia. While current practice dictates that the patient receiving conscious sedation be monitored and evaluated before, during, and after the procedure by trained practitioners, a post-anesthesia evaluation is not required (71 FR 68691)
  • The evaluation must be completed and documented by any practitioner who is qualified to administer anesthesia. In accordance with §482.52(a), anesthesia must be administered only by:
    • A qualified anesthesiologist
    • A doctor of medicine or osteopathy (other than an anesthesiologist)
    • A dentist, oral surgeon or podiatrist who is qualifies to administer anesthesia under State law
    • A certified registered nurse anesthetist (CRNA) who, unless exempted in accordance with paragraph (c) of this section, is under the supervision of the operating practitioner or of an anesthesiologist who is immediately available if needed; or
    • An anesthesiologist's assistant who is under the supervision of an anesthesiologist who is immediately available if needed

CMS advises Hospitals to consult recognized guidelines when developing policies and procedures for post-anesthesia care.  For example the Practice Guidelines for Post-anesthetic Care, Anesthesiology, Vol. 96, No 3, March, 2002, provides the recommendations of the American Society of Anesthesiologists for routine post-anesthesia assessment and monitoring, including monitoring/assessment of:

  • Respiratory function, including respiratory rate, airway patency, and oxygen saturation; Cardiovascular function, including pulse rate and blood pressure;
  • Mental status
  • Temperature
  • Pain
  • Nausea and vomiting; and
  • Postoperative hydration
  • Depending on the specific surgery or procedure performed, additional types of monitoring and assessment may be necessary.

The Joint Commission standards PC.03.01.07 address patient care after operative or other high-risk procedures and/or the administration of moderate or deep sedation or anesthesia; a qualified LIP must discharge the patient from the PACU or hospital.

Also Joint Commission standard RC.02.01.03 addresses the documentation of operative or other high-risk procedure and/or the administration of moderate or deep sedation or anesthesia.

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