CMS SOM App. L, Tag Q-0265

The ASC must -

(1) Provide each patient with written discharge instructions and overnight

supplies. When

appropriate, make a follow-up appointment with the physician, and ensure that all

patients are informed, either in advance of their surgical procedure or prior to

leaving the ASC, of their prescriptions, post-operative instructions and physician

contact information for follow-up care.

Interpretive Guidelines: §416.52(c)(1)

Each patient, or the adult who accompanies the patient upon discharge, must be provided

with written discharge instructions.

Either before the surgery or before discharge each patient must be provided with:

• Prescriptions they will need to fill associated with their recovery from surgery;

• Written instructions that specify actions the individual should take in the immediate

post-operative, post-discharge period to promote their recovery from the surgery;

warning signs of complications to be alert for, etc.

• How to contact the physician who will provide follow-up care to the patient. When

appropriate, the ASC must make an appointment with the physician for follow-up care.

The ASC must also provide supplies, such as gauze, bandages, etc., sufficient for the

patient’s needs through the first night after the surgery.

Survey Procedures: §416.52(c)(1)

• Determine whether there is a copy of the discharge instructions provided to the

patient in the patient’s medical record.

• Look at the discharge instructions in the sample of records under review, as well as

for patients being discharged while the ASC is being surveyed. Do the discharge

instructions include post-operative care instructions for the patient? Do they indicate if

the patient was provided prescriptions, if applicable? Do they provide physician contact

information?

• Ask the ASC when and how it schedules follow-up appointments with the physician

for patients.

• Ask the ASC what types of supplies it typically provides to patients upon discharge.

Observe whether patients being discharged during the survey are provided any supplies to

cover their overnight needs.