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Description
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Percentage of patients who are taken to the operating room for an elective surgical procedure under regional, monitored anesthesia care (MAC), and/or general anesthesia who have been documented for having all three preoperative components addressed during the preoperative phase of care:
1. The purpose for the recommended procedure AND goals of care discussion has been documented in the medical record.
2. An identification of significant co-morbid condition(s), if any, documented in the medical record within 30 days of operation date.
3. An updated history and physical (H&P), documentation that recent laboratory values were reviewed, and documentation of the site and side of surgery in the medical record within the 24 hours prior to surgery.
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