Anesthesia Time Documentation (Start/Stop, Relief, Interruptions)

Patient: [Patient name], MRN: [MRN], DOB: [DOB]
Date of Service: [Date of service]
Location: [Facility]; [Anesthetizing location]
Procedure: [Procedure name]
Anesthesia Type: [General / Regional / MAC / Other]
Care Model: [personally performed / medically directed / medically supervised]; [Provider name(s), credentials, and roles]

(Use 24-hour time format HH:MM throughout. If any required time is unavailable, insert "Not documented—requires reconciliation." Omit conditional sections entirely when they do not apply. For simple continuous cases with no handoffs, interruptions, or medical direction, include only the header, Anesthesia Time Summary, and Attestation.)

Anesthesia Time Summary

Anesthesia Start Time: [HH:MM]
Anesthesia Stop Time: [HH:MM]
Total Billable Minutes: [Total billable minutes]
Time Continuous: [Yes / No]

Authoritative Time Source: [Time source]

Billable Time Segments

(Include only if multiple billable segments exist due to handoffs or interruptions. List segments chronologically without overlap. Sum of segment minutes minus interruption minutes must equal Total Billable Minutes.)

• Segment [#]: Start [HH:MM]; Stop [HH:MM]; [Minutes] minutes

  Responsible Provider: [Name, credentials]

  Role/Supervision Model: [personally performed / medically directed / medically supervised] (If medically directed, identify the directing physician.)

• (Repeat for each additional segment)

Non-Billable Interruptions

(Include only if any interruption occurred. State specific cause; avoid vague terms like "delay.")

• Interruption [#]: Start [HH:MM]; Stop [HH:MM]; [Minutes] minutes excluded

  Reason: [Specific reason for interruption]

  Patient status: [Airway, hemodynamics, monitoring status]

  Monitored by: [Name, credentials, location]

  Resumption trigger: [Event that triggered resumption of anesthesia care]

• (Repeat for each additional interruption)

Provider Handoffs

(Include only if an intraoperative handoff occurred. Handoff times should correspond to segment boundaries.)

• Handoff Time: [HH:MM]

  Outgoing Provider: [Name, credentials]

  Incoming Provider: [Name, credentials]

  Handoff Type: [temporary relief / permanent transfer]

  Reason: [Reason for handoff]

  Patient status: [Airway, hemodynamics, key infusions]

  Incoming provider accepted care: [Yes]

• (Repeat for each additional handoff)

Medical Direction Attestation

(Include only when medically directed care is billed. If responsibilities were split between physicians, identify who performed each element.)

• Preanesthetic evaluation: [Physician name] at [HH:MM]
• Anesthesia plan established by: [Physician name]
• Participation in key portions: [Induction at HH:MM; Emergence at HH:MM] (Include times only for portions where physician was present)
• Monitoring at frequent intervals: [Attestation of monitoring frequency]
• Immediate availability maintained: [Yes / Description]
• Post-anesthesia evaluation: [Physician name] at [HH:MM]

[Brief attestation confirming all required medical direction elements were satisfied]

Stop Time Clarification

(Include only when there was a delay between patient readiness for transfer and actual transfer.)

• Time patient ready for transfer: [HH:MM]
• Reason for delay: [Specific reason]
• Care provided during interval: [Description of ongoing anesthesia care]

Attestation

I attest that the documented anesthesia times reflect continuous anesthesia care as recorded in the anesthesia record, that any non-billable interruptions and provider handoffs are explicitly documented above, and that the Total Billable Minutes reconcile to the segments and interruptions documented herein.

Signature: [Provider name], [Credentials], [Role], [Date], [HH:MM]