The following article appeared in the Nov./Dec. 2010 issue of Connection, the bi-monthly e-newsletter from the AAAHC.
Q: When a Medicare-certified ASC and an office practice share the same electronic medical record, how does the ASC meet the Medicare requirement for a separate record?
Ray Grundman, AAAHC surveyor, AAAHC senior director, external relations: Both AAAHC and CMS require that an individual record be established for each patient. AAAHC Chapter 6 states, "An accreditable organization maintains clinical records and a health information system from which information can be retrieved promptly. Clinical records are complete, comprehensive, legible, documented accurately in a timely manner and readily accessible to health care professionals." Standard 6.B states, "An individual record is established for each person receiving care."
Medicare Conditions for Coverage 416.47 states, "The ASC must maintain complete, comprehensive, and accurate medical records to ensure adequate patient care;" and 416.47(b) states, "The ASC must maintain a medical record for each patient. Every record must be accurate, legible, and promptly completed."
That record can either be a separate, stand alone record, or a tab or section in the practice's office record for an office-based or medical practice based surgery center.
The key is that the surgical episode can be identified from the remainder of the record and that the section of the record designated for the surgical center records can only be accessible to surgery center staff. As many office-based surgery centers migrate from paper records to an electronic medical record (EMR), they find it is more economical to share the EMR between the practice and the surgery center. Many EMRs come formatted with tabs or sections for various items, such as lab tests, EKG and x-ray reports. A separate tab or section for surgical center procedures would satisfy the requirements for both AAAHC and CMS.
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Read other columns from AAAHC:
- Can ASC Recovery Rooms Be Used for Pre-Operative Functions?
- Radiologist Required to Supervise ASC Radiological Services