DNV GL Healthcare Revises Surgical Services Documentation Requirement
DNV GL Healthcare recently updated their NIAHO Hospital Accreditation Requirements, effective January 21, 2019. DNV GL Healthcare has revised a Surgical Services requirement (SS.8) which requires an operative report that describes techniques, findings, and tissues removed or altered and is dictated or documented and authenticated by the surgeon immediately following surgery.
Revisions include the following:
- All surgeries or invasive procedures that require anesthesia services (excluding minimal or moderate sedation or topical analgesics, which are not considered to be “anesthesia”) require an operative report or a postoperative/post-procedure note if the operative report is not immediately available. (SR.2)
- When estimating blood loss in postoperative/post procedure note, specify “N/A” if there was no blood loss. (SR.4e)
- When/if information identified in the immediate post-operative/post procedure note is available elsewhere in the medical record; it is acceptable if referred to and authenticated as accurate by the attending surgeon. (SR.5)
According to DNV GL Healthcare, these changes were made to reflect accepted standards of practice regarding documentation.
These changes are applicable to DNV-accredited hospitals and are effective as of January 21, 2019. Included with today’s notice is a link to the revised NIAHO requirements and an example policy related to these revised requirements.
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