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Operative and High Risk Procedure Reports - Documenting Blood Loss and Specimens

The requirement found at RC.02.01.03 EP 6 uses the word ‘any’ that precedes both estimated blood loss (EBL) and specimen(s) removed. Does this mean that even if there was no blood loss or specimen(s) associated with a procedure that the practitioner must indicate ‘no EBL’ or ‘no specimens’ in the report?

Any examples are for illustrative purposes only.

No. If there was no blood loss and/or no specimens removed, there is no requirement for the proceduralist to document those two items, unless the organization specifically requires this level of documentation.  The word “any” was specifically chosen to reflect the need to only document those items when applicable to the procedure performed.

 
Last updated on April 28, 2020
Manual: Critical Access Hospital
Chapter: Record of Care Treatment and Services RC

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