# Anesthesia record documentation



## cmacpc (Apr 1, 2013)

Not sure on the guidelines for this.  So any help is appreciated because the group I code for does this from time to time. Here is the case I have in front of me now:
Anesthesia start time:  11:26   
Surgery start time:  11:43
Surgery end time:  12:44
Anesthesia end time:  12:50
The problem is that on the anesthesia record where the vitals are recorded (timeline) the documentation of the vitals stops @ 12:37.  In the comments section the last entry is  "surgery started 11:43"  nothing after that.  My question is regarding documentation on the timeline, is it as criticle part of the record as everything else.  My guess is yes, and  without this documented what time would you be able to bill up to? is the record is incomplete?  Any insight would be appreciated.

TIA


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## Michele Hannon (Apr 1, 2013)

Anesthesia time as defined by the ASA:
Anesthesia time begins when the anesthesiologist begins to prepare the patient for anesthesia care in the operating room or in an equivalent area and ends when the anesthesiologist is no longer in personal attendance, that is, when the patient is safely placed under post-anesthesia supervision.

Most anesthesia records require that you record vital signs every five minutes. An auditor would expect to see recorded vital signs within 5 minutes of the anesthesia end time. Does your record indicate "out of room" time? or Recovery room arrival time? (or return to Same Day Surgery time if the patient by-passed the recovery room)


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## cmacpc (Apr 2, 2013)

*Anesthesia documentation*

Thanks for your response, in reply to your questions there is no out of room time.  Patient in PACU @ 1250.


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## aaron.lucas (Apr 2, 2013)

"Patient in PACU @ 1250" should be good, because that represents the time the anesthesiologist released the patient to recovery, and that would support the anesthesia end time of 1250.  The only issue might be like Michele Hannon said, having the vitals not documented after a certain point, depending on who you're billing and how particular they are about stuff could cause a problem.  You might want to ask the anesthesiologist if there's a reason they didnt check or didnt document vitals, or whatever other reason there's such a gap there.  Maybe they can shed light on that, and possibly note that in the record.


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## cmacpc (Apr 2, 2013)

*Anesthesia documentation*

Thank you for the information.  I will contact the provider & keep tabs on their future documentation.


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