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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.

^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: Office Based Surgery
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 Types of changes and an explanation of change type: Editorial changes only: Format changes only. No changes to content. | Review only, FAQ is current: Periodic review completed, no changes to content. | Reflects new or updated requirements: Changes represent new or revised requirements.
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