The postoperative period is the last phase after the preoperative and intraoperative phases of the perioperative phases, when anaesthesia providers care for the surgical patient by assessing the patient after recovery from anaesthesia.
During the postoperative period, patients are recovering from anaesthesia and surgery. In a tertiary care hospital, the postanaesthesia care unit (PACU) is staffed to monitor and care for patients who are recovering from the immediate physiologic effects of anaesthesia and surgery during this postanaesthesia recovery period.
Patients in the PACU are monitored according to a hospital policy stating the standards for postanaesthesia care during the postanaesthesia recovery period intended to encourage quality patient care. A hospital policy stating the standards for post anaesthesia care will apply to postanaesthesia care in all locations (Ronald and Manuel, 2011).
Recording of monitoring data according to standards and anaesthesia practice parameters, provides the documentation to support discharge decisions.
The ongoing, systematic collection and analysis of data on the patient’s status in recovery in the PACU support decisions during this unique transition period, about moving the patient from delivery of anaesthesia in the operating room to the less acute monitoring on the hospital ward and, in some cases, independent function of the patient at home.
Health Information Management (HIM) / Medical Records (MR) practitioners need to be aware that monitoring findings are entered into the patient’s medical record by written or electronic entry.
Patients are discharged from the PACU (or recovery monitoring is discontinued) by one of the following specific PACU discharge criteria (JCI, 2011) using discharge scoring systems which may vary in your hospital but certain general principles are universally applicable (Ronald and Manuel, 2011) :
- “the patient is discharged (or recovery monitoring is discontinued) by a fully qualified anaesthesiologist or other individual authorised by the individual(s) responsible for managing the anaesthesia services” (JCI, 2011), and who accepts responsibility for discharge of patients from the PACU
- “the patient is discharged (or recovery monitoring is discontinued) by a nurse or similarly qualified individual in accordance with postanaesthesia criteria developed by the hospital’s management, and the patient’s record contains evidence that criteria are met” (JCI, 2011)
- “the patient is discharged to a unit which is capable of providing postanaesthesia or postsedation care of selected patients, such as a cardiovascular intensive care unit or neurosurgical intensive care unit, among others” (JCI, 2011)
HIM/MR practitioners also need to be aware that the time of arrival and discharge from the recovery area (or discontinuation of recovery monitoring) is recorded.
If your hospital is undergoing a hospital accrediation process from for example by the Joint Commission International (JCI), then documentation of postanaesthesia care is measured through JCI Standard ASC.6 which states that “Each patient’s postanaesthesia status is monitored and documented, and the patient is discharged from the recovery area by a qualified individual or by using established criteria.” For hospitals undergoing a hospital accreditation process or re-applying for accreditation status by the JCI, then JCI Standard ASC.6 and its three (3) Measurable Elements (MEs) that measure postanaesthesia care must be fully met during the survey process.
With this background about the postoperative period when anaesthesia providers care for the surgical patient by reassessing the patient after recovery from anaesthesia in a PACU of any tertiary care hospital, and the requirement of a hospital accreditation standard like that of the JCI Standard ASC.6, the HIM/MR practitioner’s role with regards to postanaesthesia documentation in the medical record would be to verify if the medical record contents for a patient include, (i) a postanaesthesia evaluation note, which is a progress note documented by any individual qualified to administer anaesthesia in the an the appropriate section of a common pre- and postanaesthesia evaluation note, and (ii) a separate recovery room record.
A postanaesthesia evaluation note (Michelle and Mary, 2011) includes :
- “patient’s general condition following surgery”
- “description of presence/absence of anaesthesia-related complications and/or postoperative abnormalities”
- “blood pressure, pulse, presence/absence of swallowing reflex and cyanosis”
After the completion of surgery, patients are taken to the recovery room where the anaesthesiologist and recovery room nurse are responsible for documenting a PACU or recovery room record.
Postoperative documentation – the recovery room record, regarding the discharge of the patient from the postsedation or postanaesthesia care area (e.g., recovery room) adapted from Michelle and Mary (2011) includes :
- “patient’s general condition upon arrival to recovery room”
- “postoperative/postanaesthesia care given”
- “patient’s level of consciousness upon entering and leaving the recovery room”
- “description of presence/absence of anaesthesia related complications and/or postoperative”
- “abnormalities (may be documented in progress notes)”
- “monitoring of patient vital signs, including blood pressure, pulse, and presence/absence of swallowing reflex and cyanosis”
- “documentation of infusions, surgical dressings, tubes, catheters, and drains”
- “written order dated, timed and authenticated for example by the anaesthesiologist releasing patient from recovery room” is documented in the surgeon’s orders according to hospital policy stating the standards for post anaesthesia care
- “documentation of transfer to nursing unit or discharge home”, also according to hospital policy stating the standards for post anaesthesia care
HIM/MR practitioners, do take note that anaesthesiologists sometimes document the postanaesthesia evaluation progress notes on a special form located on the reverse side of the anaesthesia record, so no documentation elements are forgotten.
Here is a graphic of the types of anaesthesia care documentation found in the medical record for any surgical patient when anaesthesia providers care for the surgical patient through the preoperative, postoperative, and intraoperative phases of the perioperative period (you can view a larger image by clicking on the image below which will open in a new tab of your current browser window).
I believe I have covered all the required surgical information documentation for anaesthesia care required in a medical record with this post on anaesthesia care
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
Ronald, DM & Manuel, CP Jr 2011, Basics Of Anaesthesia, 6th edn, Elsevier Saunders, Philadelphia, PA, USA
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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.
