CMS SOM App. A, Tag A-0954

in the case of emergencies:

(iii) An assessment of the patient must be completed and documented after

registration (in lieu of the requirements of paragraphs (b)(1)(i) and (ii) of this section) when

the patient is receiving specific outpatient surgical or procedural services and when the

medical staff has chosen to develop and maintain a policy that identifies, in accordance

with the requirements at § 482.22(c)(5)(v), specific patients as not requiring a

comprehensive medical history and physical examination, or any update to it, prior to

specific outpatient surgical or procedural services.

Interpretive Guidelines §482.51(b)(1)(iii)

A pre-surgical assessment must be completed and documented after registration for any

outpatient surgery or procedure requiring anesthesia, and except for emergencies, when it is

determined by the medical staff policy in place that addresses specific patient characteristics

that may not necessitate the need for a comprehensive medical H&P examination and testing, or

updated examination, prior to surgery. Patient specific considerations that may be used in

determining the necessity for a pre-surgical assessment may include but are not limited to, the

following:

• patient age (considering the need for H&Ps based on pediatric, adult, or geriatric age

differences),

• diagnosis,

• the type and number of procedures scheduled to be performed on the same surgery date,

• known comorbidities (e.g. cardiac or pulmonary disease), and

• planned anesthesia level (e.g. minimal sedation vs general anesthesia).

Additionally, the policy should require the consideration of national standards and guidelines of

practice for the assessment of specific types of patients prior to specific outpatient surgeries and

procedures and in accordance with State and local laws.

Survey Procedures §482.51(b)(1)(iii)

• Review a sample of medical records of patients receiving outpatient surgery to determine

whether evidence exists that pre-surgical assessments and updates have been completed

and documented after registration, but prior to surgery or a procedure requiring

anesthesia services except in the case of emergencies.

• Review the hospital’s policies and procedures regarding pre-surgical assessments for

outpatient surgical or procedural services and updates to determine if they are consistent

with the regulatory requirement.