Surgeon
Surgeon of record which will be used on claim
Anesthesia ID #1 (#2, etc.)
All anesthesia providers - Anesthesiologist(s) and CRNA(s) - who cared for the patient, including Supervising MDs.
Primary Location
Anesthetizing location in the Facility
Primary Anesthetic Used
Per CMS, only 1 type of anesthetic may be chosen
PreOp Eval for OSA
Was the patient evaluated for Obstructive Sleep Apnea
PreOp Eval for GERD
Was the patient evaluated for Reflux
PreOp Eval for Glaucoma
Was the patient evaluated for Glaucoma
PreOp Eval for PONV Risk Factors
Was the patient evaluated for PONV risk factors
PreOp Eval for Alc/Tob
Was the patient evaluated for excessive alcohol/tobacco use
Attestation of Current Medications
Patients current home medications (including route, dosage, and frequency) are documented in the patient’s EHR
Surgical Safety Checklist
Time out complete, anesthesia machine checked, site is marked (if indicated), pulse oximeter placed on patient and functioning.
Anesthesia Start
Patient enters Operating Room OR Time the Labor Epidural placement has started
Anesthesia Ready
Time at which anesthesia team has completed patient induction, secured access, performed any necessary procedures (art lines, nerve blocks, etc.), and “handed” care of the patient to nursing staff for positioning and prepping. OR Time the Labor Epidural placement has ended
Surgery Start
Time of incision or procedure start (or start of C-Section following Labor Epidural)
Surgery End
Time surgery or procedure has ended (or end of C-Section following Labor Epidural)
PACU/ICU Arrival
Time the patient entered PACU or ICU for handoff
Anesthesia End
Time the primary Anesthesia team stops continuous service
Handoff Protocol Used
Was documentation of your facility’s handoff protocol used
Pain Score
PACU pain score within 15 minutes of arrival
Complication Reasons
List of complication reasons
First Case Delay
Reasons List of first case delay reasons
Same Day Cancellation Reasons
List of same day cancellation reasons