Wiki Anesthesia record documentation

[cmacpc]

I have come across this from time to time. The surgeon states on the op report ASA classification 2 the conflict is that the anesthesia record is ASA 3. Patient is having Endoscopic Ultrasound with MAC, but "during process of receiving MAC Anesthesia & endoscopy patient was having gurgling sounds and decision was made to intubate for patient safety.
Is this a compliance issue? Does any one else have surgeons put ASA classifications on op rpts? I don't see other surgeons do this except this particular one and he always seems to off by one.

Thanks,
RS

 

[Michele Hannon]

The ASA code is assigned by the anesthesia provider not the surgeon. Would tend to go with the anesthesia record.
MAC to general should not be an issue as long as medical necessity for anesthesia intervention has been documented.