JAHCO, CMS, and hospital credentialing boards have already established required elements of the operative report; one of which is "implants". 

The implant's serial number is recorded into the EMR during the procedural encounter when the device is scanned into the EMR in the procedural area.  This information is then pulled into the templated operative report.

The "implant card" is given to the patient, usually by the perioperative nurses since this hard-copy is included on a limited paper chart that tends to go with the patient when the patient is moving from procedural area to recovery. 

The above is the current process. Of course finding historic records is limited by the hospital's record-keeping prior to widespread adoption of EMR's with "procedural encounter" environments.   

In the current era, the petitioner request is redundant.

As mentioned in an earlier comment, the specific implant used is a required element of the operative report. The exact serial number / lot number is also located in the hospital records of the operation and maintained for 10 years at a minimum. To ask surgeons to track down these numbers and include them in the dictated operative report is not only redundant, but takes time away from direct patient care. The serial numbers of every implant are recorded and maintained by the hospital. Asking a surgeon to redundantly do the same is unnecessary and actually harmful in that it would create unnecessary delays in patient care.

I agree with the points made in the previous comments. The current process already provides appropriate documentation and tracking of implanted devices through the operative report, EMR, and existing perioperative workflow.

Adding another reporting requirement would mostly duplicate information that is already being collected and maintained but not immediately available to surgeons when dictating operative record. While older records may be more difficult to access, a new process would not fix those historical gaps.

For current and future procedures, the necessary information is already being documented by the hospital. I do not believe an additional reporting process would provide meaningful benefit and would instead add unnecessary administrative burden only to the surgeons which are already over burdened with administrative tasks.

As prior comments have noted, implant serial numbers are already maintained in the hospital or surgery center EMR under the operative record, as is other information such as the lot number of medications. While this may be a separate EMR from a surgeon’s office EMR (as described in the petition), especially if the surgeon’s practice is independent of the hospital or surgery center where the procedure is performed, the requested change to the operative note would not reconcile this issue, as operative notes are maintained by the hospital/surgery center, not necessarily the surgeon’s clinic EMR. 

While it’s regretful that the individual patient listed in this petition notes difficulty accessing this information, there is no evidence that this is a widespread problem. The proposed change adds further documentation burden to the physician/surgeon, unnecessarily duplicates existing documentation and workflow, and will not result in a meaningful increase in access to this information for patients, at least insofar as the rationale listed in the petition.