Ambulatory Surgery Record Documentation

Ambulatory facilities that perform surgery are called ambulatory surgery centers (ASC). Patients who have surgery in an ASC still must have a history and physical prior to surgery present within the health record. The patient must have signed the appropriate consent documentation prior to the procedure. Much like an inpatient health record containing a surgery component, an ambulatory surgery record must contain operative reports and notes, diagnostic and therapeutic documentation, consultations, and discharge notes at the conclusion of the treatment.

Ambulatory surgery centers will also perform discharge follow-up phone calls, where a nurse will call the patient within 24 to 48 hours postdischarge to check on the patient. The nurse will assess pain levels and address any immediate or future needs of the patient related to the treatment. This conversation must be documented in the health record. The Joint Commission and the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) have requirements applicable to the ambulatory surgery center setting. CMS’s Conditions for Coverage for ambulatory surgical centers govern those that seek Medicare reimbursement.