Notice: JCAHO Clarifies Requirements for Operative Report Under Standard IM.6.30

Published: Dec 29, 2004
The JCAHO has clarified requirements for operative report documentation and time frames, in the January 2005, Volume 3, Issue I JCAHO online periodical "The Source". Requirements for operative report documentation and time frames for entering the documentation into the medical record are outlined under the Management of Information Chapter of the JCAHO standard manuals, under standard IM.6.30. The wording for this standard has been changed for the 2005 standards and addresses operative and other high-risk procedures, rather than listing operative or other procedures as worded in the 2004 standards. The 2005 standard revision and the elements of performance for this standard that address operative report requirements and time frame are outlined below.

2004 Standard IM.6.30:

The medical record thoroughly documents operative or other procedures (JCAHO definition of operative and other procedures: procedures including operative, other invasive, and noninvasive procedures that place the patient at risk. The focus in on procedures and therefore is not meant to include use of medications that place patients at risk) and the use of moderate or deep sedation or anesthesia.

2004 Elements of Performance:

2. In operative progress note is entered in the medical record immediately after the procedure

3. Operative reports dictated or written immediately after a procedure record the name of the primary surgeon and assistants, findings, procedures performed and description of the procedure, estimated blood loss, as indicated, specimens removed, and postoperative diagnosis.

4. The completed operative report is authenticated by the surgeon and made available in the medical record as soon as possible after the procedure

2005 Standard IM.6.30:

The medial record thoroughly documents operative or other high-risk procedures (JCAHO definition of operative or other high risk procedures: procedures including operative, other invasive, and noninvasive procedures that place the patient at risk. The focus is on procedures and therefore is not meant to include use of medications that place patients at risk) and the use of moderate or deep sedation

2005 Elements of Performance:

2. Operative or other high risk procedure reports dictated or written immediately after an operative or other high risk procedure record appropriate information as defined by the medical staff. (Immediately after an operative or other high risk procedure is defined by the JCAHO as upon completion of the operation or procedure, before the patient transferred to the next level of care

   
  • This is to ensure that pertinent information is available to the next caregiver. In addition, if the surgeon accompanies the patient from the operating room to the next unit or area of care, the operative note or progress note can be written in that unit or area of care).      

    3. An operative or other high risk procedure progress note is entered in the medical record immediately after the procedure, when the full operative or other high risk procedure report cannot be entered into the record immediately after the operation or procedure.

       
  • . The completed operative or other high risk procedure report is authenticated by the surgeon and made available in the medical record a soon as possible after the procedure      

    The article, entitled "Understanding Standard IM.6.30" elaborates on the 2005 standard; addressing requirements for what must be included in an operative report, and states that the standard requires operative reports for procedures that are operative, invasive and noninvasive in nature, if those procedures place the patient at risk. The JCAHO gives examples of these types of procedures as endoscopic and angiogram procedures (as well as the obvious operative and invasive procedures). The 2005 standard now allows the organization to determine which operative, other invasive and noninvasive procedures are provided by that organization that place the patient at risk (determined by the scope of services and population served). It is anticipated that there will be an expectation by the JCAHO that each organization has reviewed all types of procedures conducted within the organization and determined (with determination driven by the medical staff) which of these fall within the categories of operative, invasive, and noninvasive procedures that place the patient at risk.

    Additionally, the JCAHO outlined what must be included in a postoperative report. The JCAHO states that a full operative report should contain a greater amount of detail than a brief postoperative note, which is commonly written when time or technical availability of transcription does not allow for a comprehensive postoperative report immediately following the procedure. When a brief postoperative note is entered into the record, a full, comprehensive postoperative report should be generated at a later date. The article outlined the following to be included as full operative report documentation elements for any operative procedure, high-risk procedure and use of moderate or deep sedation or anesthesia:

       
  • Name of primary surgeon and assistants -Procedure(s) performed -Description of the procedure(s) -Findings -Estimated blood loss as indicated -Specimens removed -Disposition of each specimen -Postoperative diagnosis      
          
  • The JCAHO does not specifically require documentation of a preoperative diagnosis, however notes that his may be helpful to allow for comparison of preoperative and postoperative diagnosis.            

    The JCAHO states that for those instances when a postoperative report cannot be immediately filed into the patient's record, a comprehensive handwritten progress note must be entered into the record (immediately following the procedure, before the patient is transferred to the next level of care). This report may be in a condensed form version and may contain less detail than a full operative report, however it should contain comparable information and at a minimum, it must include:

       
  • Procedure(s) performed -Name of the primary surgeon and any assistants -Findings -Technical procedures used -Specimens removed -Disposition of each specimen -Estimated blood loss -Postoperative diagnosis       

    The Joint Commission states the completed operative report or brief operative note should be authenticated by the surgeon or licensed independent practitioner and should be made available in the medical record prior to transfer of the patient to the next level of care. However the article presented an interesting amount of JCAHO flexibility in the area of who may actually compete an operative note (the article specifically referred to the term note, not full report). The JCAHO does not have a policy for whom can sign a progress note. They do suggest however, (and we recommend from a risk management standpoint) that the licensed independent practitioner performing the procedure write and authenticate the report (and/or note), as he or she may be the most knowledgeable regarding the required information and therefore the most qualified to complete the documentation. However the JCAHO will defer to organizational policy, as well as state and federal regulation, allowing a nurse or other clinician to write the progress note for the physician conducting the procedure to sign. The JCAHO specifically stated in the article, Understanding IM.6.30, "If the organization's policy requires the physician to sign the note, then a nurse or clinician is prohibited from doing so. If the organization's policy indicates that any staff member can prepare a summary and sign it, then a nurse, clinician, or resident can sign it". While this may appeal to some organizations who would like to increase operative report compliance related to the elements of performance for this standard (specifically entering an operative note immediately after the procedure), we strongly recommend your organization check with your liability (risk) carrier about this practice. We continue to recommend that the individual performing the procedure document the operative report, however we do present this interesting JCAHO information for reader consideration.

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