Health Information Technologies and Processes

Post Anesthesia Evaluation §482.52(b)(3))

  • 1.  Post Anesthesia Evaluation §482.52(b)(3))

    Posted 30 days ago
    Interested in knowing how your facility captures this evaluation.  Do capture this information on a paper form or enter electronically into the system and what EMR do you currently use?

    We are on Meditech client server and this is still a paper process for us and hoping there is a better solution.

    Thanks.

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    Deanna Heinrich
    Director of HIM/Privacy Officer
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  • 2.  RE: Post Anesthesia Evaluation §482.52(b)(3))

    Posted 30 days ago

    Hi, are you referring to the anesthesiologists? If so, they use their own documentation system that interfaces into our EMR once completed and signed off on. Meditech has a way to document this but our Anesthesiologists don't like it.


    Thanks,

    Karla

     






  • 3.  RE: Post Anesthesia Evaluation §482.52(b)(3))

    Posted 29 days ago
    Hi Deanna,
    I am not sure if I am answering your exact question, so I apologize if I am not. We have Meditech 6.15, but were previously Magic and it was the same process. Our anesthesia providers document the pre-op info on a patient questionnaire that they review with the patient (after the patient has completed their portion), the surgical anesthesia record is on paper and scanned, and the post-op anesthesia note is done within pDoc. We also have separate pDoc templates for procedures that are not related to surgery. Those types of procedures would be PICC/Midline Insertion, Intubation, Labor Pain Epidural, Labor Pain Intrathecal, consultation, Block Note, etc. We like that they use pDoc notes for these procedures because we can more easily track the activity for the professional billing.

    We are looking at an anesthesia software that integrates with Meditech, but that is not within this budget year. I don't know when we will actually make a purchase.
    Katie

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    Kathryn Wood, RHIA
    Assist Dir of Information Systems/Privacy Officer
    War Memorial Hospital
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