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doctor-only
Soap Sizes:100g
must match the clinical record and consent form Physical status modifier : The selected P1-P6 modifier must be documented in the anesthesia record and must match what appears on the claim Provider credentials and role : Whether an anesthesiologist, CRNA, or resident provided care, and what supervision arrangement was in effect Intraoperative monitoring documentation : Continuous vital sign monitoring record, including blood pressure, heart rate, oxygen saturation, and temperature where applicable Post-anesthesia evaluation : Documentation that the patient was assessed after emergence and prior to discharge from the anesthesia recovery area Across specialties, the documentation principle is the same: if it isn’t documented, it didn’t happen
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