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Record of Care, Treatment, and Services (RC) Standards
RC.02.01.03 The patient's clinical record contains documentation on any operative or other high-risk procedures and the use of moderate or deep sedation or anesthesia.
EP2 Provisional diagnosis
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Record of Care, Treatment, and Services (RC) Standards
RC.01.01.01 The practice maintains complete and accurate clinical records.
EP1 Components of the medical record
EP5 Information on the medical record
EP7 Dated entries
RC.02.01.01 The clinical record contains information that reflects the patient's care, treatment, and services.
EP2 Clinical information
RC.02.01.03 The patient's clinical record contains documentation on any operative or other high-risk procedures and the use of moderate or deep sedation or anesthesia.
EP1 Operative or other high-risk procedures
EP2 Provisional diagnosis
EP5 Operative report
EP6 Operative report information
EP7 Operative progress note
EP8 Postoperative information
EP9 Post-sedation or postanesthesia care
EP10 Discharge criteria
EP11 Practitioner responsible for discharge
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Element of Performance
A licensed independent practitioner involved in the patient's care documents the provisional diagnosis in the medical record before an operative or other high-risk procedure is performed.
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