For any procedure where deep sedation or anesthesia is given, an operative report must be dictated immediately upon the completion of the procedure.
A postoperative PowerNote is required awaiting the dictated report availability in the record. This note must be entered before the patient is transferred to the next level of care. This progress note includes the following:
- Name of primary surgeon and his/her assistant(s)
- Procedure perform
- Description of procedure findings
- Estimated blood loss
- Any specimen removed
- Postoperative diagnosis