When we’re reviewing your clinicians’ data, it may be helpful to know what we are looking for in order for us to verify to CMS that your data is accurate and complete. Measure 358 requires documentation that a non-emergent surgical patient had their personalized risks or postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and documentation that the surgeon discussed these risks with the patient.
This documentation may be found in the patient’s medical record. The relevant document should be made available to the auditor for the patient requested.
What tools are available to help us meet this measure?
The American College of Surgeons offers a surgical risk calculator that can be used to determine the patient’s overall risk prior to surgery. If using this free resource, save or print the results and scan and upload into the medical record.
Regardless of the service used, you must document the calculator used and the communication of the assessment results with the patient.