H & P needed for local anesthesia???

  1. Ok, all you wonderful Radiology nurses. Being a department of ONE, I need some input.
    I am primarily involved in CT and US guided interventional procedures. We ONLY get H & P's on patients have procedural sedation. QUESTION IS: Do you guys get H & P's for patients receiving LOCAL anesthesia only? I am trying to look through JCAHO and CMS guidelines to try and find my answer, but am having NO luck.

    If you would, please share your thoughts and any documentation you may have.
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    Joined: Sep '05; Posts: 28


  3. by   jer_sd

    At my facility we use a short form H+P for minor procedures.

    Historicaly LPs and other procedurs preformed by diagnostic rads were excempt based on the assumption that there is a recent H+P in the chart. Now this is under the microscope and we may need to ensure that there is a H+P for all procedures, not all diagnostic exams (back to LP isssues) but all PICCS even if local only, biopsies ect need atleast a short form H+P.
  4. by   BootsyRNPA
    Where I work we get H&P fo everything except piccs, ptc change with no sedation, neph no sedation, lp no sedation, myelo no sed everything else gets an h&p