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.
^As applicable to the procedure, it is acceptable to document 'quantitative blood loss' in lieu of 'estimated blood loss' which is common in OB/GYN procedures.
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.
^As applicable to the procedure, it is acceptable to document 'quantitative blood loss' in lieu of 'estimated blood loss' which is common in OB/GYN procedures.
Manual:
Critical Access Hospital
Chapter:
Record of Care Treatment and Services RC
Last reviewed by Standards Interpretation: July 07, 2022
Represents the most recent date that the FAQ was reviewed (e.g. annual review).
First published date: January 18, 2017
This Standards FAQ was first published on this date.
This page was last updated on June 19, 2023
with update notes of: Editorial changes only
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