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Surgical information that require documentation in medical records

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Now I have completed relevant posts on surgical information that belong to the contents of a typical medical record for a patient who had undergone surgery, I like to summarise the Joint Commission International (JCI) standards and requirements that directly affect surgical information which requires documentation in medical records.

At this juncture, I like to reiterate that I am not advocating JCI’s program for hospital accreditation. I have used their standards as a benchmark to make medical records documentation to a better quality and as evidence of proper care.

I have also run up each post with a background to a specific surgical information in the medical record, so that Health Information Management (HIM) / Medical Records (MR) practitioners are not just managing medical records literally and not understanding and knowing the background of pieces of scientific information which accumulates inside the medical records.

In my opinion, knowing the nature and structure of surgical information in a medical record make a better HIM/MR practitioner, who is able to stand up for and argue for the quality of medical and surgical information in medical records.

Someone has to fight for the quality of medical records, and who is less important and relevant than HIM/MR practitioners who are the rightful custodians of medical records. I think it is not HIM/MR management practice is not only about medical records assembly, filing, coding, preparing statistical reports and medico-legal processing, etc., but accruing knowledge on HIM/MR management with regards to “WHAT is this thing we are managing”, “WHY are we keeping this?”, and ”HOW can we contribute to the quality of documentation?”.

From the post Medical information that require documentation in medical records (this link will redirect you to a new tab of your current browser window), I had presented all the necessary requirements about of medical information that require documentation in a medical records which explicitly stated what is to be documented in a medical record and also standards which implicitly indicated  medical information that require documentation in a medical record.

For surgical information that require documentation in a medical record, I have a count of twelve (12) standards – or also as one can say “requirements”, which explicitly state what is to be documented in a medical record. There are no standards that indicate implicitly any necessity for surgical information to be documented in a medical record.

I have tabulated all the 12 requirements in some charts. But before displaying the charts on the 12 requirements, allow me to summarise the perioperative period for a patient scheduled for surgery in the pictorial below. I think this chart below is relevant to understanding the 12 requirements (a larger view of this chart is displayed in a new tab of your current browser window by clicking on this chart).

And now, the charts below (a larger view of each chart is displayed in a new tab of your current window, by clicking on each chart) show the 12 requirements for surgical information.

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I believe, a HIM) / MR practitioner working in a hospital must be knowledgeable enough of the surgical information contents in the medical records in his or her custody and to contribute greatly to their quality. The medical records must contain all of the surgical information as I spoken of above, recorded in them. This condition is regardless of the type of hospital they work at, irrespective if his or her hospital had acquired JCI accreditation status or one that is seeking JCI accreditation status or it is one that is not seeking JCI accreditation status at all.

References :
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA

Patient care after surgery is planned and documented

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Another surgical information that goes into the medical record is the postsurgical care plan to surgical patients. A postsurgical care plan is important for discharge planning and future planning are based on medical and nursing care plans after surgery. The Joint Commission International (JCI) Standard ASC.7.4 also emphasises the importance for such a plan through its statement which reads, “Patient care after surgery is planned and documented.”

As each surgical patient’s postsurgical medical and nursing care needs usually differ, immediate postsurgical care is planned and includes medical, nursing, and others as indicated by the patient’s defined needs. The postsurgical care plan which can begin before surgery based on the patient’s assessed needs and condition, includes the level of care, care setting, follow-up monitoring or treatment, and need for medication.



The postoperative phase (which is each surgical patient’s postsurgical care period) continues until the patient is released from the surgeon’s care. When the client is discharged from the postanesthesia care unit (PACU), the surgeon will later decide the next level of care and the care setting for the patient.  The surgeon documents in the postsurgical plan whether the patient goes either directly to an inpatient hospital bed or to the outpatient ambulatory unit for observation or to discharge the patient to the patient’s home.

The postsurgical care plan will also contain information on follow-up monitoring of the postoperative patient’s return to normal (baseline) respiratory function and cardiopulmonary function and the patient is free from signs of a wound infection within 72 hours after surgery.

Postoperative discomforts like pain – which is usually most severe immediately after the patient’s recovery from anaesthesia, postoperative nausea, urinary retention,  postoperative constipation, postoperative flatus all require treatment and need medication. The treatment(s) and medications form part of the postsurgical care plan documentation.

A Health Information Management (HIM) / Medical Records (MR) practitioner will find among the contents of a medical record for a patient who had undergone surgery, a postsurgical plan(s) documented in the patient’s medical record by the responsible surgeon or verified by the responsible surgeon by co-signature on the documented plan entered by the surgeon’s delegate. The nursing postsurgical plan of care and when indicated by the patient’s needs, the postsurgical plan of care provided by others are also documented in the patient’s medical record. These are often documented in the progress notes. However, nursing care plans are not usually filed in the permanent patient record. The date and time for each of the plans of care documented in the patient’s medical record are evidence to verify that each planned care was provided and documentation was done within 24 hours of the surgery.

With this post, I believe I have completed posts on anaesthesia care and surgical care which have explicit reference to surgical documentation in a medical record for a patient who undergoes surgery.

References :
Caroline, BR & Mary, TK 2012, Textbook of basic nursing, 10th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia, USA

Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA

Sue, CD & Patricia, KL 2011, Fundamentals of Nursing: Standards & Practice, 4th edn, Delmar, Cengage Learning, NY, USA

Physiological status monitoring and documentation during and immediately after surgery

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Health Information Management (HIM) / Medical Records (MR) practitioners need to be aware that a medical record for a patient who had undergone surgery, has his or her monitoring findings of their physiological status written in his or her medical record. A patient’s physiological status is continuously monitored during (intraoperative) and immediately after surgery (postoperative), appropriate to the patient’s condition and the procedure performed.

I think HIM/MR practitioners also need to know why a patient’s physiological status is continuously monitored during and immediately after surgery and what is documented into the medical record, as I have outlined below.

Results of monitoring trigger key intraoperative decisions as well as postoperative decisions, such as return to surgery, transfer to another level of care, or discharge.

The focus of intraoperative care is to promote the patient’s achievement of expected intraoperative outcomes directed at placing the patient in a safe environment free from injury. The Operating Room (OR) team monitors the patient throughout the surgical procedure for complications, for example the patient’s fluid and electrolyte balance is maintained.

Before the client is transferred to the Post-Anaesthesia Care Unit (PACU), evaluation of the patient is based on reassessment of findings for the patient during surgery. The specific data on the achievement of patient outcomes in the intraoperative phase is documented on the OR record, i.e. the Operative Record.

The postoperative phase continues until the patient is released from the surgeon’s care. After surgery, the on-going care is directed toward restoring physiological functioning, promote healing, and prevent complications and return the patient to the preoperative health status. The patient is monitored for (i) respiratory status for example, one postoperative assessment finding on airway and respiratory status shows the patient is able to expel an oral airway and exhibits return of gag reflex after the patient is extubated, (ii) circulatory status, (iii) neurologic status (monitoring the patient’s level of consciousness), (iv) fluid and metabolic status (monitoring the patient’s (a) gastrointestinal system– for example, with abdominal surgery, abdominal distension to detect internal haemorrhage is monitored and (b) genitourinary system – for example, assessment for bladder distension, (v) level of discomfort or pain, and (vi) wound management.

Monitoring information guides medical and nursing care and identifies the need for diagnostic and other services.

Physiological monitoring during intraoperative and postoperative phases by the OR team is related to the same requirement for physiological monitoring during anaesthesia, which you can refer to from the earlier post Check your medical record for patient monitoring during anaesthesia (this link will open in a new tab of your current browser window).

Physiological monitoring during intraoperative and postoperative phases is documented in the postoperative progress notes and the Operative Record. The surgeon or nurse is responsible for documenting the medical and nursing aspects of physiological status monitoring.

If your hospital is seeking a hospital accreditation status for example the Joint Commission International (JCI) accreditation status or already JCI accredited or plans for a JCI re-survey, then it is only normal to comply with the JCI Standard ASC.7.3 which states “Each patient’s physiological status is continuously monitored during and immediately after surgery and written in the patient’s record.”

References :
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA

Sue, CD & Patricia, KL 2011, Fundamentals of Nursing: Standards & Practice, 4th edn, Delmar, Cengage Learning, NY, USA

Written surgical report

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In Malaysia, in most instances Health Information Management (HIM) /
Medical Records (MR) practitioners may only find the postoperative note documented in the medical record. The postoperative note is an operative or other high-risk procedure report documented by the surgeon after surgery in the postoperative phase. This after surgery phase is when the client leaves the Operating Room (OR) and is taken to a Post-Anaesthesia Care Unit (PACU) and continues until the patient is discharged from the care of the surgeon upon completion of the operative or other high-risk procedure and before the patient is transferred to the next level of care.

In addition to the postoperative note, a surgeon may also dictate an operative record in hospitals where dictation services are available, in Malaysia or in other countries.Some hospitals may create special forms to facilitate an operative record documentation.

Thus, it is common to find a comprehensive operative progress note documented by the surgeon written in the progress notes in the patient medical record. However, a HIM/MR practitioner may also find that the patient medical record often contains as well as a transcribed operative record. Both of this documentation is authenticated by the responsible surgeon.

HIM/MR practitioners must not be confused between postoperative evaluations documented by the surgeon with postanaesthesia evaluations documented by the anaesthesiologists.

The content for the postoperative progress notes and/or operative record will normally contain documentation as follows:

  1. patient’s vital signs and level of consciousness
  2. any medications, including intravenous fluids, administered blood, blood products, and blood components
  3. any unanticipated events or complications (including estimated blood loss and blood transfusion reactions) and the management of those events, or the absence of complications during the procedure
  4. name of the procedure and techniques associated with the performance of surgery
  5. description of other procedures performed during operative episode
  6. description of gross operative findings, including organs explored
  7. postoperative diagnosis
  8. name of operative surgeon and assistants
  9. surgical specimens sent for examination
  10. documentation of ligatures, sutures, number of packs, drains, and sponges used
  11. date, time, and signature of responsible surgeon

If your hospital is seeking a hospital accreditation status for example the Joint Commission International (JCI) accreditation status or already JCI accredited or plans for a JCI re-survey, then it is only normal to comply with the JCI Standard ASC.7.2  which requires :

(i) that there is a surgical report or a brief operative note (which may be used in lieu of the written surgical report) available prior to the patient leaving the postanesthesia recovery area to support a continuum of postsurgical supportive care, thus meeting Measurable Element (ME) 2 compliance for this standard, and

(ii) that the surgical report or a brief operative note is documented with at least the minimum six (6) elements as required by JCI Standard ASC.7.2, ME 1 (which I have already included in the list above) for the written surgical report or brief operative note in the patient’s medical record.

References :
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA

Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA

17 POSSIBLE REASONS HOW ELECTRONIC MEDICAL RECORDS (EMR) might support day-to-day patient care

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I stumbled upon the post “Improving Patient Care through EMRs” from the Plus91 blog by Pooja Raval who used to work for Plus91, a healthcare Technology firm developing Innovative High Quality Solutions for the Indian Healthcare Industry based in Pune. Maharashtra, India.

In her post she offers a list of reasons why Electronic Medical Records (EMRs) is  a modern revolution in the field of healthcare with all its numerous benefits to doctors that eventually can improve patient care. She listed twelve good reasons. I thought her post was pretty interesting and decided to expand on it, so it would seem a little more comprehensive. So here I have reproduced her thoughts, and expanded on her post what I think from my literature search are the extra EMR benefits.

Now I have seventeen (17) reasons!

This list (as below) has no particular order of importance, nonetheless I have retained her order in writing the 12 reasons and added on the five (5) more reasons. Click on any thumbnail image to view the presentation in the same tab of your current browser window, press Esc key to continue reading the article).

I am sure Health Information Management (HIM) / Medical Records (MR) practitioners reading this post working in an EMR workplace, will know if these 17 reasons hold water. If these reasons justify a shift to EMRs, then HIM/MR practitioners at non-EMR workplaces who still practice on paper-based medical records could view these reasons as a reason to propose a planned cut back on paper-based medical records quickly and make the swift transition to EMRs.

However, I am certain It is common for individuals to have anxiety about the transition as it represents a change in their very comfortable routine. Others may be simply “technophobic” and deplore the idea of spending any more time interacting with technology than they already have to.

One way to address these issues creating buy-in from doctors and staff is to highlight the ways in which the EMR implementation may save time and make life easier.

There is no process in the office that will not be affected – and hopefully improved – by the EMR. Communicating this in a way that emphasises the positive aspects of the change, while carefully addressing employee fears and concerns, can build excitement for the transition and ultimately ensure its success.

References :
Carolyn, KS & Laura LSO, ‘Usability: Patient–Physician Interactions and the Electronic Medical Record’, in J Stephan & MG Frank (eds) 2012, Information and Communication Technologies in Healthcare, Boca Raton, FL, USA, pp. 123-144

Neil, SS (ed.) 2011, Electronic Medical Records A Practical Guide for Primary Care, Humana Press, New York, USA

Pooja,  R 2011, Improving Patient Care Through EMRs, viewed 22 August 2012, <http://technology4doctors.blogspot.com/2011/03/improving-patient-care-through-emrs.html>

Prathibha, V (ed.) 2010, Medical quality management : theory and practice, 2nd edn, Jones and Bartlett Publishers, Sudbury, MA, USA