Important reminder about post-op orders at St. Vincent

During The Joint Commission’s recent survey at St. Vincent, it was noted that some brief post-op/post-procedure notes were not completed before the patient’s level of care changed (i.e., no brief post-op note before the patient left the PACU or left the OR to go straight to the ICU). Ultimately, this could jeopardize our ability to care for our patients and our accreditation.

Please review the below pertinent excerpts from the Medical Staff Clinical Rules and Medical Records Completion - SVH Policy related to post-op note requirements.  The Joint Commission will return soon to follow up on the post-op note process. 

From the Clinical Rules:

(Section 10.4.2: Inpatient Records, Operative/Procedure Reports)

• All operative/procedure reports must be dictated or electronically entered immediately following surgery, this operative/procedure report must be in medical record no later than 48 hours after surgery. If the full operative report is not placed in the medical record immediately after surgery or the procedure due to a transcription or filing delay, a brief operative/procedure note should be entered in the medical record immediately after surgery or the procedure and before the patient is transferred to a different level of care. 

• Separate anesthesia notes shall be entered in the record for pre-operative, intra operative and post-operative documentation. The anesthesia post-op note/post anesthesia note may be completed and documented by an individual qualified to administer anesthesia. The post anesthesia note will be completed within 48 hours after surgery. 

*Please note that “should” referenced above will need to go through the review & update process as this is required by The Joint Commission.

From the Medical Records Completion SVH Policy, Timely Completion:

• An Operative or other high-risk Procedure Report is written or dictated upon completion of the operative or other high-risk procedure and before the patient is transferred to the next level of care.

  • *Note 1: The exception to this requirement occurs when an operative or other high risk procedure progress note is written immediately after the procedure, in which case the full report can be written or dictated within 48 hours after surgery.

  • *Note 2: If the Practitioner performing the operation or high-risk procedure accompanies the patient from the operating room to the next unit or area of care, the report can be written or dictated in the new unit or area of care.

• Operative Report or Procedure Note:

  • Operative reports shall be documented according to the Medical Staff Clinical Rules.

  • Postoperative Note/Post procedure Note/Brief Op:

    • Operative reports shall be documented according to the Medical Staff Clinical Rules.