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.

EP6 Operative report information

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Record of Care, Treatment, and Services (RC) Standards

RC.01.01.01 The practice maintains complete and accurate clinical records.
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.

Element of Performance

The operative or other high-risk procedure report includes the following information:

The name(s) of the licensed independent practitioner(s) who performed the procedure and his or her assistant(s)
The name of the procedure performed
A description of the procedure
Findings of the procedure
Any estimated blood loss
Any specimen(s) removed
The postoperative diagnosis

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