Example: Patient expires on 02-12-20xx and documentation indicates the Anesthesia Start Date was 03-12-20xx. Other documentation in the medical record supports the date of death as being accurate, but no other documentation of the Anesthesia Start Date can be found. Since the Anesthesia Start Date is outside of the parameter for care (after the Discharge Date [death]) and no other documentation is found, the abstractor should leave blank.

If the Anesthesia Start Date is incorrect (in error) but it is a valid date and the correct date can be supported with other documentation in the medical record, the correct date may be entered. If supporting documentation of the correct date cannot be found, the medical record must be abstracted as documented or at “face value.”

Examples: The anesthesia form is dated 12-10-2007, but other documentation in the medical record supports that the correct date was 12-10-2009. Enter the correct date of 12-10-2009 as the Anesthesia Start Date.

An Anesthesia End Date of 11-20-20xx is documented but the Anesthesia Start Date is documented as 11-10-20xx. If no other documentation can be found to support another Anesthesia Start Date, then it must be abstracted as 11-10-20xx because the date is not considered invalid or outside the parameter of care.

Other Suggested Sources:

• Intraoperative record
• Circulator record
• Post-anesthesia evaluation record
• Operating room notes

Note: The anesthesia record is the priority data source for this data element, if a valid Anesthesia Start Date is found on the anesthesia record, use that date. If a valid date is not on the anesthesia record, other suggested data sources may be used in no particular order to determine the Anesthesia Start Date.

Priority Source:

• Anesthesia record