Outpatient Surgery Center
Outpatient Surgery Center is also known as Ambulatory Surgery Center. An outpatient surgery center is where people of all ages go to have surgical procedures and then released to their homes. The patients do not “need advanced care after a procedure requiring hospitalization.” (Peden, 2017) Patients do need to be relatively healthy and low risk of complications to have procedures done outpatient. (Peden,2017) Patients may not be having a surgical procedure done; it can be injections, that require some level of sedation, as in pain management. (Nurse, Registry, n.d., Wyatt, 2019) It includes those who choose to have elective surgeries such as breast augmentations. (Wyatt, 2019)
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Patients' outpatient experience begins at the time it's scheduled. “If hybrid records are used, they need to be located and transferred to the facility.” (Peden, 2017) Any pre-procedure testing should be done before the patients arrive on procedure day. (Wyatt, 2019) Upon arrival, the patient must register at the desk. (Wyatt, 2019) During the registration process, they will make sure they have the patient's demographics, financial information, and privacy choice per HIPPA guidelines. (Wyatt, 2019) The patient should be asked if they have advanced directives. (Wyatt, 2019) The patient will sign a consent to treat. (Wyatt, 2019) Registration will also collect any copayments that need to be paid before surgery. (Wyatt, 2019) “They will put a band on the patient with their name, DOB, DOS, MRN number, FIN number, and their physician's name.” (St. Luke’s, Wyatt, 2019) They will ask the patient to confirm all information is correct on the ID band. (St. Luke’s, Wyatt ,2019)
In acute care, the patient might have already been registered; and all information collected if they went through the ER.
A preoperative nurse will check the patient's vitals, do assessments, get patients' current medications, allergies, and medical history. (Wyatt, 2019) They will put an allergy band on the patient. (Wyatt ,2019) Also making sure all diagnostic tests are in the patient's record. (Wyatt ,2019) Nurses will document in the preoperative report. (Wyatt ,2019) They will start The Physician Admission Orders and Discharge Medication Reconciliation Form. (St. Luke’s, Wyatt, 2019) The preoperative nurse will get the patient prepared for surgery and start an intravenous line and hang ordered fluids and any ordered medications. (St. Luke’s, Wyatt, 2019) They will answer any questions the patient might have. (Wyatt ,2019) They will also make sure the patient and the physician sign any consents. (Wyatt ,2019)They will do their preoperative charting. (St. Luke’s, Wyatt, 2019)
In an acute care setting, the patient will most likely be prepped in the ER or if they are already inpatient and head straight to surgery.
A phlebologist will draw any labs that are needed before the procedure begins, if required or ordered by the physician. The lab might do blood ABO typing in case the patient needs a transfusion. (Wyatt, 2019) Radiology will also perform any ordered test before surgical procedures, or some procedures require the use of the radiology team. (Wyatt, 2019) An example would be nerve ablation. (Wyatt, 2019) Any diagnostic testing done with be documented in the patient's medical records. (Wyatt, 2019)
In acute care, diagnostic procedures will most likely be done before the patient heads to the surgical unit, and the results might be why the patient is having surgery. (St. Luke’s, Wyatt, 2019)
The Pharmacy will provide all medications needed for patients in the outpatient surgery center. (St. Luke’s, Wyatt, 2019) Their job is to make sure medications are available in correct areas, correct dosing if applicable, and provide safe storage. (St. Luke’s, Wyatt, 2019) “Their position is no different than in acute care settings besides stat medications being ordered and supplying the whole hospital with medications.” (Peden, 2017)
The physicians or surgeons' job is to make sure the patient understands the procedure and the risk associated with it and to get the informed surgical consent signed. (Peden, 2017) The physician will be sure to document the preop diagnosis. (Wyatt, 2019) The physician then performs the procedure and documents the intraoperative report. (St. Luke’s, Wyatt, 2019) They will provide follow-up information and does the surgical report with post-op diagnosis and methods they used during surgery and any standing and orders for the recovery area and provide discharge instructions. (Wyatt, 2019) If any samples of tissues are tested, there needs to be a pathology report. (Wyatt, 2019) They will give the nurses instructions to go over with the patient's responsible party and provide any prescriptions the patient is to take at home. (Wyatt, 2019)
In the acute care setting, the physician's role will not be much different, except it may be surgeons perform general surgeries and hospitalists overseeing patient care. “There may be more than one physician, PAs, or surgeons in the surgical unit in either case. Operations may be done on emergency cases.” (Peden, 2017)
Anesthesiologist preoperative will talk to patients before they go back to surgery. (Wyatt, 2019) They will determine the appropriate sedation for the patient and the procedure. They will ask patients “what allergies they have and any medical conditions or any previous issues with anesthesia.” (Texas Anesthesiologist, n.d.) The anesthesiologist will ask and check for any removable dental ware. (Wyatt, 2019) They will ask the patient if they have any questions and will explain the type of sedation that they will use. (Wyatt, 2019) They also may give patients medications before heading back to the operating suite to relax the patient. (Wyatt, 2019) Alternatively, they can also inject a joint for the physician before the patient heads back to the operating room. (Wyatt, 2019) They will document their care on the pre-anesthesia report. (Wyatt, 2019) Intraoperatively they will monitor the "patient's vitals; heart rate, rhythm, breathing, blood pressure, body temperature, and body fluid balance." (Texas Anesthesiologist, n.d.) “Giving the anesthetic medications for the duration of the procedure” (Texas Anesthesiologist, n.d.) and will establish airways for specific anesthesia. The Anesthesiologist team includes Nurse Anesthetist and assistances to help before, during, and after procedures. They may help “monitor or give medications” (Texas Anesthesiologist, n.d.) throughout the process if they are licensed to do so. “Postoperative, the anesthesiologist will address any reactions, side effects, and manage pain.” (Texas Anesthesiologist, n.d.) They will finish the intraoperative report and postoperative reports.
“In the acute care setting, they might have to intubate the patient for longer surgeries and based on the type of anesthesia used.” (Texas Anesthesiologist, n.d.)
“Postoperative nurses are responsible for monitoring the patient vitals after the procedure, how they are waking up from anesthesia, and any surgical sites for bleeding and IV fluids.” (Texas Anesthesiologist, n.d.) They administer medications ordered per standing orders or if the physician orders additional medications. (Wyatt, 2019) They alert physicians or anesthesiologist of any complications. The nurse will make sure there is a postoperative report (recovery room report) that is filled out. (Wyatt, 2019) When the nurse feels the patient is ready to be discharged, they go over postoperative care, signs, and symptoms of infection, and any limitations. (St. Luke’s, Wyatt, 2019) The nurse will also finish The Physician Admission and Discharge Medication Reconciliation Form and provided the discharge summary. (St. Luke’s, Wyatt, 2019) The nurse will provide discharge instructions to the responsible adult with you and also explain to the patient and give any written prescriptions to be filled. (Wyatt, 2019) The nurse gets the papers sign, and she takes the patient out to the car by wheelchair and helps the patient get into the car and buckled in. (Wyatt, 2019)
Postoperative nurses in acute settings will still provide the same about of care, except for the patient will be transferred to a unit in the hospital or discharged. (Wyatt, 2019)
In the acute care setting, healthcare providers would provide more than primary surgical care. They would manage any critical issues related to diagnosis and surgical care. “Care would be monitored twenty-four hours a day until the patient recovers enough to go home.” (Peden, 2017). Nursing and Physicians roles would be more entailed and hands-on in the patients' continued care. (Wyatt, 2019)
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In the Toledo area, most are owned by hospitals, such as Sugri+Care is owned by St. Luke's, ProMedica owns Parkway Surgery Center. (Wyatt, 2019) In some outpatient surgery centers, they will have their own billing and HIM professionals. Most likely to be based somewhere else on the campus of who owns the surgery centers. (Wyatt, 2019) “Even though the hospitals may own the outpatient surgery centers, they must be run independently from the main hospitals.” (Peden, 2017)
Outpatient Surgery Centers in the “State of Ohio have to be licensed by the state under section 3702.30 of the Ohio Revised Code of Regulatory Operations." (Ohio.Gov, 2019) They don't undergo yearly visits but do get unplanned visits from CMS if they want to participate in federal programs. (Ohio.Gov, 2019) During these visits, it has to be shown that they are following "state and federal laws and rules." (Ohio.Gov, 2019) “The Bureau of Regulatory Operations is responsible for licensure in Ohio.” (Ohio.Gov, 2019) They also have a "Certification Unit that does certification for CMS." (Ohio.Gov, 2019) For CMS, they usually require an outpatient surgery center to be accredited by the Joint Commission even though it is stated as optional. (Sayles, 2016) Most faculties will have either or accreditation from "TJC, AAAHC, AAAASF ANS HFAP." Meeting the conditions of participation (COPs) and conditions for coverage CFCs." (Sayles, 2016)
The coding used in outpatient surgery centers ICD-10-CM for diagnosis and HCPCS/CPT used for "coding procedures and services provided." (Peden, 2017) "Level 1 codes are current procedural terminology codes for physician services. (Peden, 2017) Level II in HCPCS are national codes developed by CMS and used for nonphysician services; like injections, medical equipment." (Peden, 2017) The typical payment for ambulatory care centers is a fee for service. (Peden, 2017) Surgical centers usually have a basic fee for using the facility and then they bill for additional services provided. (Peden, 2017) Physicians receive reimbursement based of Level 1 codes. (Peden, 2017) The patient pays for the services provided based on their health insurance (copayment/deductibles) Medicare pays for outpatient surgery centers based on “ASC system, which is based on “HCPCS/CPT codes “for procedure and get a percentage based of ACSs.” (Gibson, 2018) Physicians pay is based off “MPFS or PFS is based on the resource based related value scale (RBRVS).” (Peden, 2017)
Critical documentation requirements include the patient must have a medical record on file from at the outpatient surgery center. “They must meet the FQHCs for Medicaid and Medicare for payment.” (Peden, 2017) Registration and Demographics, Physician, dates and times of visit, pertinent medical information, diagnosis, medications, allergies, reports on labs and diagnostic procedures, x-ray reports, signed surgical consent, preoperative report, anesthesia report, operative report, recovery room report, pathology report, discharge summary and diagnosis." (Peden, 2017)
‘Issues with documentation can arise out of hybrid records; the patients' medical records could be stored at another facility and have to transport to the surgical center.” (Peden, 2017)
Paper section of the medical records could have missing documents or filed wrong, or outdated information. (Wyatt, 2019) Depending on the record format, it could be easier or harder to find what you are looking for. “In Source-Oriented Format it is organized by the source, Intergraded format is in chronological order.” (Peden, 2017) EHR will provide some information if they are used in the outpatient surgery center.
The Role of HIM professional in outpatient surgery is "managing the information, regulatory compliance and electronic information systems, and administrative functions." (Peden, 2017) In Hybrid records, their job would be to know "how and locate records as well as supervising the staff of the hybrid records." (Peden, 2017) They also may play a role in the implementation of EHRs. HIM professionals can also be coders. (Peden, 2017)
Future trends in Outpatient surgery centers is they are becoming more desirable due to an "increase in technology and anesthetics." (Dentler, 2018) “With these advancements, more complicated surgeries will be provided on an outpatient basis in the future, reducing hospital inpatient stays and decreasing the cost of surgical procedures.” (Dentler, 2018)
Current issues are most outpatient surgical centers use hybrid records. The paper portion of the records are “stored in one location and, when needed, have to be driven to another facility or can be faxed.” (Peden, 2017) There is a concern for privacy and data breaches and increased the chance of records or parts getting lost. (Peden, 2017) In an emergency, paper format records might not be available and affecting patient care and outcomes. (Peden, 2017) Patient compliance with aftercare can be low and may not follow directions provided, leading to infections and complications. (Peden, 2017) There is limited privacy in outpatient surgery centers. (Peden, 2017) Observation is under four hours, and sometimes it takes longer for complications to develop. (Peden, 2017)
I find it interesting that outpatient surgery centers can provide so many different types of procedures and have all the materials they need in one location. I do know in some elective surgeries; the physicians do bring some of the materials from their offices. Learning that St. Luke's has its dedicated outpatient center attached to the main hospital, and they also own Surgi+Care was interesting. (St. Luke’s, 2019) Their discharge papers say Surgi+Care, but their Physician Admission Orders and Discharge Medication Reconciliation Form says St. Luke's. (St. Luke’s, 2019) “It was interesting to learn that they have to be run separately but owned by the same entity.” (Ohio Department of Health, 2019) I’m sure this is a confusing concept for many who work in the faculties and have to float — keeping in mind how each separate until runs based on the hospital-owned outpatient center then their stand-alone on the same campus.
- Dentler. J. (2018, May 21). Outpatient Migration:6 Trends and Developments. Becker’s Hospital Review. Retrieved https://www.beckershospitalreview.com/hospital-management-administration/outpatient-migration-6-trends-and-developments.html
- Gibson, H. (2018, November 20).. 5 Critical Things to Know Ambulatory Surgery Center Billing Services. M-Scribe Medical Billing. Retrieved from https://www.m-scribe.com/blog/5-critical-things-to-know-ambulatory-surgery-center-billing-services
- Nurse Registry. (n.d.). Nursing in the Ambulatory Surgery Center. Retrieved from
- Ohio Department of Health. (n.d.). Ambulatory Surgical Facilities. Retrieved from
- Peden, A. H. (2017). Freestanding Ambulatory Care. Comparative Health Information Management. 4e. (p70-114). Boston, MA: Cengage Learning.
- Sayles, N. (2016). Health Information Management Technology An Applied Approach.
- 5e. (p85-100). Chicago, IL. American Health Information Management Association.
- Texas Society of Anesthesiologist. (n.d.) The Role of the Anesthesiologist from Surgical Anesthesia to Critical Care Medicine and Pain Medicine.
- Retrieved from https://www.tsa.org/public/anesthesiologist_role.php
- Wyatt. (2019) Personal discharge Instructions and The Physician Admission Orders and Discharge Medication Reconciliation Form.
- St. Luke’s Outpatient Surgery Center
- Surgi+Care Outpatient Surgery Center
- Work Experience
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