CMS SOM App. A, Tag A-1005

11)

[The policies must ensure that the following are provided for each patient:]

482.52(b)(3) - A postanesthesia evaluation completed and documented by an

individual qualified to administer anesthesia, as specified in paragraph (a) of this

section, no later than 48 hours after surgery or a procedure requiring anesthesia

services. The postanesthesia evaluation for anesthesia recovery must be completed

in accordance with State law and with hospital policies and procedures that have

been approved by the medical staff and that reflect current standards of anesthesia

care.

Interpretive Guidelines §482.52(b)(3)

A postanesthesia evaluation must be completed and documented no later than 48 hours

after surgery or a procedure requiring anesthesia services. The evaluation is required any

time general, regional, or monitored anesthesia has been administered to the patient.

While current practice dictates that the patient receiving moderate sedation be monitored

and evaluated before, during, and after the procedure by trained practitioners, a

postanesthesia evaluation performed by someone qualified to administer anesthesia as

specified in §482.52(a) is not required under this regulation. (71 FR 68691)

The postanesthesia evaluation must be completed and documented by any practitioner

who is qualified to administer anesthesia; this need not be the same practitioner who

administered the anesthesia to the patient. In accordance with §482.52(a), anesthesia

must be administered only by:

• A qualified anesthesiologist;

• A doctor of medicine or osteopathy (other than an anesthesiologist);

• A dentist, oral surgeon, or podiatrist who is qualified to administer anesthesia

under State law;

• A certified registered nurse anesthetist (CRNA), who, unless exempted in

accordance with paragraph (c) of this section, is under the supervision of the

operating practitioner or of an anesthesiologist who is immediately available if

needed; or

• An anesthesiologist’s assistant who is under the supervision of an anesthesiologist

who is immediately available if needed.

Although §482.12(c)(1)(i) provides broad authority to physicians to delegate tasks to

other qualified medical personnel, the more stringent requirements of §482.52(b)(3) do

not permit delegation of the postanesthesia evaluation to practitioners who are not

qualified to administer anesthesia.

The calculation of the 48-hour timeframe begins at the point the patient is moved into the

designated recovery area. The evaluation generally should not be performed immediately

at the point of movement from the operative area to the designated recovery area. Rather,

accepted standards of anesthesia care indicate that the evaluation should not begin until

the patient is sufficiently recovered from the acute administration of the anesthesia so as

to participate in the evaluation, e.g., answer questions appropriately, perform simple

tasks, etc. While the evaluation should begin in the PACU/ICU or other designated

recovery location, it may be completed after the patient is moved to another inpatient

location or, for same day surgeries, if State law and hospital policy permits, after the

patient is discharged, so long as it is completed within 48 hours. The 48 hour timeframe

for completion and documentation of the postanesthesia evaluation is an outside

parameter. Individual patient risk factors may dictate that the evaluation be completed

and documented sooner than 48 hours. This should be addressed by hospital policies and

procedures (71 FR 68690).

For those patients who are unable to participate in the postanesthesia evaluation (e.g.,

post-operative sedation, mechanical ventilation, etc.), a postanesthesia evaluation should

be completed and documented within 48 hours with notation that the patient was unable

to participate. This documentation should include the reason for the patient’s inability to

participate as well as expectations for recovery time, if applicable. For those patients

who require long-acting regional anesthesia to ensure optimum medical care of the

patient, whose acute effects will last beyond the 48-hour timeframe, a postanesthesia

evaluation must still be completed and documented within 48 hours. However, there

should be a notation that the patient is otherwise able to participate in the evaluation, but

full recovery from regional anesthesia has not occurred and is not expected within the

stipulated timeframe for the completion of the evaluation.

The elements of an adequate post-anesthesia evaluation should be clearly documented

and conform to current standards of anesthesia care, including:

• Respiratory function, including respiratory rate, airway patency, and oxygen

saturation;

• Cardiovascular function, including pulse rate and blood pressure;

• Mental status;

• Temperature;

• Pain;

• Nausea and vomiting; and

• Postoperative hydration.

Depending on the specific surgery or procedure performed, additional types of

monitoring and assessment may be necessary.

Survey Procedures §482.52(b)(3)

• Review a sample of medical records for patients who had surgery or a procedure

requiring general, regional or monitored anesthesia to determine whether a post

anesthesia evaluation was written for each patient.

• Determine whether the evaluation was conducted by a practitioner who is

qualified to administer anesthesia.

• Determine whether the evaluation was completed and documented within 48

hours after the surgery or procedure.

• Determine whether the appropriate elements of a postanesthesia evaluation are

documented in the medical record.