Guidance to Keep Up-to-Date Patient Records: Q&A With David Ott, Founder of Gateway Surgery Center

David Ott, MD, founder of Gateway Surgery Center in Phoenix, highlights the center's biggest challenge for meeting the accreditation standards of the Accreditation Association of Ambulatory Health Care and how the facility is working overcome the challenge.

Q: What was Gateway Surgery Center's biggest challenge in maintaining accreditation?

Dr. David Ott: Our area of most difficulty was clinical records and making sure that patient records are always up-to-date. There are all these new regulations by CMS that are coming out with documentation, and the amount of administrative work is burdensome. For example, every case now has to have an operation note that details pre- and post-operation diagnoses of patients, the particular procedure that was done and resulting complications, if there was any.

Q: What is the facility doing to overcome challenge?

DO: We had to bring on a new full-time nurse whose position is equivalent to an administrator just because of the new regulation, and that nurse floats between various parts of center to make sure all documentation is being filled out. Fortunately, that administrator was also able to streamline the process of filling out operation notes and ensure those get done. What they have created is a short form for the operation notes, which takes less than 30 seconds to fill out. Often, nurses in the procedure room will ask us after the procedure to fill in the form and have us verify and sign it.

To download the brief operation note form used by Gateway Surgery Center for adaptation and use in your ASC, click here (doc).

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