CMS SOM App. A, Tag A-0959

removed or altered must be written or dictated immediately following surgery and

signed by the surgeon.

Interpretive Guidelines §482.51(b)(6)

The operative report includes at least:

• Name and hospital identification number of the patient;

• Date and times of the surgery;

• Name(s) of the surgeon(s) and assistants or other practitioners who performed

surgical tasks (even when performing those tasks under supervision);

• Pre-operative and post-operative diagnosis;

• Name of the specific surgical procedure(s) performed;

• Type of anesthesia administered;

• Complications, if any;

• A description of techniques, findings, and tissues removed or altered;

• Surgeons or practitioners name(s) and a description of the specific significant

surgical tasks that were conducted by practitioners other than the primary

surgeon/practitioner (significant surgical procedures include: opening and

closing, harvesting grafts, dissecting tissue, removing tissue, implanting devices,

altering tissues); and

• Prosthetic devices, grafts, tissues, transplants, or devices implanted, if any.

Survey Procedures §482.51(b)(6)

Review a minimum of six random medical records of patients who had a surgical

encounter. Verify that they contain a surgical report that is dated and signed by the

responsible surgeon and includes the information specified in the interpretive guidelines.