Anesthesia Documentation Lagging

A survey taken by the Academic Health Sciences Centre of Canada and published in the U.S. National Library of Medicine found wide-ranging inconsistencies between recorded anesthetic data. To conduct the survey, the research team provided questionnaires to four different adult McGill University hospitals. Anesthesiologists were asked to rank operational variables on a scale of 1 to 5. There were 23 preoperative variables and another 33 intraoperative variables to rank according to importance.

Roughly 90% of the surveys sent by the Academic Health Sciences Centre research team were completed and returned. The research team only studied the results turned in by the McGill hospitals’ staff anesthesiologists.

Most Important Anesthetic Variables

In preoperative documentation, anesthesiologists reported two critical pieces of medical data to record. Anesthesiologists cited the patient’s allergy status as one of these two primary pieces of information. The other critical preoperative data to be recorded was the examination of the patient’s airway.

In intraoperative documentation, anesthesiologists cited the patient’s vital signs as the single most important variable to be recorded.

Recorded Anesthetic Data

After receiving the completed surveys regarding the most important anesthetic variables, the Academic Health Sciences Centre research team found that the only variable to be recorded on every patient’s medical records during anesthesia was the anesthesiologist’s name.

The patient’s allergy status was the most recorded preoperative variable, appearing on roughly 84% of medical charts. Intraoperative documentation showed a wide range of recorded data. Some anesthesiologists recorded items such as start times of the anesthesia, while other anesthesiologists recorded nothing more than the patient’s estimated blood loss.

Why is Anesthetic Documentation Important?

In terms of medical accuracy, there is a large need to improve anesthetic documentation. Inconsistencies during anesthetic documentation inhibit the medical community’s ability, as a whole, to distribute, analyze, and improve upon anesthetic data correlating with surgical performance. With more consistent anesthetic records, patients may benefit from a better communication of anesthesia-related medical information.

In terms of medical billing and coding, it is increasingly critical to maintain thorough, accurate, and consistent medical records across all areas of practice for the following reasons:

• Precise clinical anesthetic documentation describes the correct combination of diagnostic and/or treatment code for the medical biller and coder to implement.
• When medical billers and coders are able to depict the most accurate version of the surgical procedure, the medical practice is able to maximize reimbursement and minimize the need for resubmission of insurance claims.
• By maximizing the medical practice’s reimbursements and minimize the need to resubmit insurance claims, patients are happier. The practice functions in a more efficient manner. In turn, the medical practice is able to maximize revenue and profits while earning an effective reputation for easily managing health insurance claims.

For informational purposes only.