TJC2026A Note for "Reason for No Regional Anesthesia"

• Topic Version for Release TJC2026A: 13
• Topic has changed since last release: Compare versions

Rationale

Updated data element definitions, allowable values, notes for abstraction, and guidelines for abstraction to provide abstractor clarification.

Description

Question

Change from: Is there physician/APN/PA documentation why regional anesthesia was not used or attempted for the procedure?

To: Is there documentation as to justification for why regional anesthesia was not used or attempted for the procedure?

Definition

Change from:

Reasons why regional anesthesia was not used or attempted for the procedure:

• Documentation of previous spinal fusion
• Documentation of patient/family refusal of regional anesthesia
• Other reasons why regional anesthesia was not used or attempted documented by physician/APN/PA

To:

Reasons why regional anesthesia was not used or attempted for the procedure:

• Documentation of previous spinal fusion
• Documentation of patient/family refusal of regional anesthesia
• Other reasons (e.g. anticoagulated patients, coagulopathies, neurologic condition) directly documented by a physician/APN/PA as to justification for why regional anesthesia was not used or attempted.

Allowable Values

Change from:

Y (Yes)   There is physician/APN/PA documentation why regional anesthesia was not used or attempted.

N (No)   There is no physician/APN/PA documentation why regional anesthesia was not used or attempted or unable to determine from medical record documentation.

To:

Y (Yes)   There is documentation as to justification for why regional anesthesia was not used or attempted.

N (No)   There is no documentation as to justification for why regional anesthesia was not used or attempted or unable to determine from medical record documentation.

Notes for Abstraction

Change from:

• To select “Yes” for this data element, documentation of a reason for not using or attempting regional anesthesia must be dated prior to or on the PACU Discharge Date. If the patient did not go to the PACU, documentation must be dated prior to or on the day of surgery.
• If reasons are not mentioned in the context of anesthesia, do not make inferences (e.g., do not assume that regional anesthesia was not used because of a bleeding disorder unless documentation explicitly states so).
  Example:
  
  • "Bleeding disorder”, review the chart for documentation about reason why regional anesthesia was not used or attempted. If no further documentation select “no”.
  • “Recommend general anesthesia due to history of spinal fusion”, select “yes”.
• “Other” reasons for not using or attempting regional anesthesia must be documented by a physician/APN/PA.
• Exceptions to physician/APN/PA documentation of a reason for no regional anesthesia:
  • Patient family refusal may be documented by a nurse, but must be dated prior to or on the PACU Discharge Date (or prior to or on the date of surgery if the patient did not go to the PACU). Patient/family refusal of any form of regional anesthesia is acceptable. Example: Patient refused spinal anesthesia, select “Yes.”
  • Historical documentation present at the patient level in the electronic health record indicating the patient had a previous spinal fusion. As electronic data are available at all times during the encounter, it is acceptable to use this data for abstraction purposes.

To:

Selection of “Yes” for this data element:

• Documented history of spinal fusion present in the patient’s electronic health record is acceptable as a stand-alone reason for no regional anesthesia.
• Patient family refusal may be documented by physician/APN/PA OR a nurse, but must be dated prior to or on the PACU Discharge Date (or prior to or on the date of surgery if the patient did not go to the PACU). Patient/family refusal of any form of regional anesthesia is acceptable.
  • Example: Patient refused spinal anesthesia, select “Yes.”
• Other reasons (e.g. anticoagulated patients, coagulopathies, neurologic condition) directly documented by a physician/APN/PA as justification for why regional anesthesia was not used or attempted. Documentation of a reason for not using or attempting regional anesthesia must be dated prior to or on the PACU Discharge Date. If the patient did not go to the PACU, documentation must be dated prior to or on the day of surgery.
  • Example: “Recommend general anesthesia due to history of bleeding disorder”, documented by physician/APN/PA select “yes”.

Selection of “No” for this data element:

• There is no documentation as to justification why regional anesthesia was not used or attempted, or if documentation is unclear. If “Other” reasons are not mentioned in the context of anesthesia, do not make inferences.
  • Example: "Bleeding disorder”, review the chart for documentation about reason why regional anesthesia was not used or attempted. If no further documentation select “no”

Guidelines for Abstraction - Inclusion

Change from:

• Patient Refusal
• History of Spinal Fusion

To:

• History of Spinal Fusion
• Patient Refusal
• Other reasons (e.g. anticoagulated patients, coagulopathies, neurologic condition) directly documented by a physician/APN/PA as justification for why regional anesthesia was not used or attempted.