Anesthesia Medical Direction Attestation (CMS 7 Requirements)

(This attestation must be authored by the medically directing physician for a specific case. Populate all fields from the anesthesia record and related documentation.)

Patient Name: [Patient name]

MRN: [Medical record number]

Date of Service: [Date]

Facility/Location: [Facility and location]

Procedure: [Procedure name]

Surgeon: [Surgeon name]

Anesthesia Type: [GA / MAC / regional / neuraxial]

Anesthesia Start Time: [Start time]

Anesthesia End Time: [End time]

Medically Directing Physician: [Physician name, credentials]

Medically Directed Clinician(s):

• [Name], [Credential] ([Time segment covered])
• (Add additional clinicians as needed with their time segments)

Attestation Statement

I personally medically directed the anesthesia care for this patient and fulfilled all required physician activities for medical direction, as detailed below and/or as documented in the referenced sections of the anesthesia record.

Required Elements for Medical Direction

1. Pre-Anesthetic Examination and Evaluation

Completion: [Personally performed / Performed by another group physician]

Performing Physician (if different from directing physician): [Name, credentials]

Time completed: [Timestamp]

Documentation reference: [Pre-anesthesia evaluation note / H&P / Anesthesia pre-op note]

2. Anesthesia Plan Prescribed

Plan prescribed by physician anesthesiologist: [Yes]

Documentation reference: [Pre-anesthesia evaluation note / Anesthesia plan section]

Material intraoperative deviations from plan: [None / Describe deviation, rationale, and time]

3. Participation in Most Demanding Aspects

(Include only the subsection relevant to the anesthesia type.)

General Anesthesia (if applicable):

• Induction: [Present] at [Time]; Reference: [Anesthesia record / Note location]
• Emergence/Extubation: [Present] at [Time]; Reference: [Anesthesia record / Note location]

MAC / Regional / Neuraxial (if applicable):

• Most demanding aspect(s): [e.g., initiation of sedation, airway-risk period, block placement]
• Physician presence: [Present] at [Time]; Reference: [Anesthesia record / Note location]

4. Qualified Individuals Performed Delegated Procedures

Delegated components performed by qualified, credentialed personnel: [Yes]

Clinician(s) and coverage periods:

• [Name], [Credential], Coverage: [Start–End time]
• (List relief/break coverage with time segments as applicable)

5. Monitored at Frequent Intervals

Physician monitored course at frequent intervals: [Yes]

Evidence of monitoring: [Timestamped checks / Physician entries on anesthesia record / Intraoperative notes]

• [Time]: [Brief status or interaction] (Reference: [Anesthesia record / Intraop note])
• (Include at least one documented intraoperative monitoring point beyond induction/emergence for longer cases)

6. Immediately Available Throughout

Immediate availability maintained throughout: [Yes / No—see details below]

If any departure from immediate availability occurred:

• Reason: [Reason for departure]
• Duration: [Start time – End time]
• Covering physician: [Name, credentials / N/A]
• Medical direction criteria maintained: [Yes / No] (If no, do not complete this attestation; route to billing/compliance.)

7. Post-Anesthesia Care Provided

Post-anesthesia evaluation time: [Time]

Summary of findings: [Airway/respiratory status, hemodynamics, pain, nausea, mental status]

Interventions: [None / Description of interventions]

Disposition: [PACU / ICU / Floor / Home / Other]

Documentation reference: [PACU note / Post-anesthesia evaluation note / Anesthesia record]

Concurrency Statement

Maximum concurrent medically directed cases during this case: [1 / 2 / 3 / 4]

Services performed that would diminish scope of control: [None / Describe]

Concurrent interruptible activities (if any): [None / Activity description with times]

(If any required element above cannot be truthfully attested, do not complete this attestation. Document actual events and route to billing/compliance for appropriate billing pathway determination.)

Physician Signature: [Electronic signature / Name, credentials]

Date/Time of Attestation: [Timestamp]