Anesthesia Coding Alert

Question: We are transitioning to an electronic medical record (EMR), and I’m wondering how this may affect the documentation of epidurals. Can you clarify what our anesthesia providers need to document in the EMR? I cannot find any documentation guidelines regarding this.

Wisconsin Subscriber

Answer: The American Society of Anesthesiologists (ASA) has published some guidance for documentation of anesthesia care. While the statement may not provide exact verbiage for documenting ancillary services, such as an epidural or arterial line, the anesthesia provider should essentially be detailing all key aspects of patient care in either a paper or electronic medical record — including the provider performing the service, procedure description(s) and times, drug dosage, needle size, if applicable, and anything else related to the procedure.

With an EMR, you may be able to set up templates for specific procedures; it should allow either an override for patient-specific information or an area to make free-form notes.

For more information, see the ASA Statement on Documentation of Anesthesia Care at www.asahq.org/standards-and-practice-parameters/statement-on-documentation-of-anesthesia-care.