When it comes to patient safety in the setting of surgical procedures, the importance of adhering to established standards cannot be overstated.
For healthcare facilities accredited by QUAD A, understanding the nuances of these requirements is essential, especially when it comes to preparing patients for surgery. A question often arises: Are patients who are not receiving anesthesia, but only oral sedation, required to have a history and physical (H&P)?
The QUAD A standards clearly mandate that an H&P must be completed 30 days prior to the day of surgery. This comprehensive assessment can be conducted on the day of surgery, but delaying it carries the risk of unexpected findings that could increase the rate of cancellations. Therefore, it is generally advised that patients undergo an H&P before the day of surgery, taking into account the procedure type and the patient’s health status.
Each facility's policies and procedures should define medical clearance requirements for any type of anesthesia, aligning with nationally accepted standards like the ASA Physical Status Classification System. It's crucial to note that QUAD A does not specifically differentiate between major and minor procedures. Instead, facilities are encouraged to establish a reasonable definition in their written policies. Factors to consider include associated risks, the invasiveness of the procedure, the use of sedation, and the length of recovery.
According to Standard 8-B-4, the pre-operative clinical record includes a current history and physical examination by the physician, anesthesia provider, or the patient’s personal physician, is recorded within 30 days of procedures on all patients for major procedures and for those patients for minor procedures who require a physical exam. The medical record must contain a current medical history taken on the same day as the procedure and recorded by the physician or anesthesia provider before administering anesthesia.
In summary, while oral sedation may not be classified as anesthesia in the traditional sense, the comprehensive guidelines set forth by QUAD A underscore the importance of an H&P to ensure patient safety and optimal surgical outcomes.
Since 1980, QUAD A (a non-profit, physician-founded and led global accreditation organization) has worked with thousands of healthcare facilities to standardize and improve the quality of healthcare they provide – believing that patient safety should always come first.
