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.

EP8 Postoperative 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

Document in the medical record the following postoperative information:

The patient’s vital signs and level of consciousness
Any medications, including intravenous fluids and any administered blood, blood products, and blood components
Any unanticipated events or complications (including blood transfusion reactions) and the management of those events

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