Clinical Documentation Tip Sheets

ELECTIVE SURGERY – INPATIENT CRITERIA

PRE-OP (DECISION/ORDER DURING SCHEDULING):

Inpatient admission is indicated for 1 or more of the following: Need for pre-op stabilization of active/acute condition, e.g., infection. Care for chronic comorbidities. Patient with complex conditions such as pancreatitis, heart failure, ESRD, chronic respiratory failure, care for malnourished or frail patient. Complex surgical approach or situation anticipated, For example: Prolonged airway monitoring required, e.g., COPD with chronic respiratory failure. Other aspect or feature of procedure that indicates a likely need for prolonged postoperative care or monitoring.

POST-OP (NEED INPATIENT ORDER AFTER ADMISSION):

Inpatient admission is indicated for 1 or more of the following: Conversion to open (for laparoscopic or endoscopic procedures). Comorbidities management that prolonged stay. Complications. Failure to meet discharge criteria, e.g., not optimal recovery course. Patient Factors: e.g., not a safe discharge.

PHYSICIAN ADVISOR PROGRAM