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    Statement On Documentation of Anesthesia Care

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    Azaria W
    The document outlines standards for documenting anesthesia care, which should be thorough yet avoid duplication. It describes three phases of care - preanesthesia, intraoperative, and postanesthesia - and what should be documented in each phase, including things like medical history, monitoring data during surgery, medications, and postoperative evaluation. It notes that documentation priorities may conflict with clinical care in emergencies, and clinical care should take precedence in those situations.

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    Statement On Documentation of Anesthesia Care

    Uploaded by

    Azaria W
    45 views3 pages
    The document outlines standards for documenting anesthesia care, which should be thorough yet avoid duplication. It describes three phases of care - preanesthesia, intraoperative, and postanesthesia - and what should be documented in each phase, including things like medical history, monitoring data during surgery, medications, and postoperative evaluation. It notes that documentation priorities may conflict with clinical care in emergencies, and clinical care should take precedence in those situations.

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    The document outlines standards for documenting anesthesia care, which should be thorough yet avoid duplication. It describes three phases of care - preanesthesia, intraoperative, and postanesthesia - and what should be documented in each phase, including things like medical history, monitoring data during surgery, medications, and postoperative evaluation. It notes that documentation priorities may conflict with clinical care in emergencies, and clinical care should take precedence in those situations.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    45 views3 pages

    Statement On Documentation of Anesthesia Care

    Uploaded by

    Azaria W
    The document outlines standards for documenting anesthesia care, which should be thorough yet avoid duplication. It describes three phases of care - preanesthesia, intraoperative, and postanesthesia - and what should be documented in each phase, including things like medical history, monitoring data during surgery, medications, and postoperative evaluation. It notes that documentation priorities may conflict with clinical care in emergencies, and clinical care should take precedence in those situations.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    Statement on Documentation of Anesthesia Care

    Committee of Origin: Committee on


    Quality Management and Departmental Administration (QMDA)

    (Approved by the ASA House of Delegates on October 15, 2003, and last amended on
    October 17, 2018)

    Accurate and thorough documentation is an essential element of high quality and safe medical care,
    and accordingly a basic responsibility of physician anesthesiologists. Anesthesia care is a
    continuum including three general phases of care: preanesthesia, intraoperative/intraprocedural
    anesthesia and postanesthesia care. To contribute to accuracy in medical records and to facilitate
    any future necessary chart review, anesthesiologists should ensure that accurate and thorough
    documentation is accomplished in all three phases of anesthesia related care. Information that is
    relevant to the perioperative care of a patient that exists elsewhere in the medical record need not
    be duplicated in the preanesthesia evaluation, the anesthesia record or postanesthesia evaluation.
    Departments and practices should develop local policies that address how information may be
    provided when documenting patient evaluations. These policies may include how information
    should be referenced and incorporated in an evaluation without requiring duplication of information
    from elsewhere in the medical record.

    Depending upon several local factors, documentation may be provided on a paper record or within
    an electronic record. Anesthesiologists may delegate to appropriately trained and credentialed
    anesthesia care team members any portion of the periprocedural record keeping, but they should
    play an active role to ensure that accurate and thorough medical record keeping is accomplished.
    Documentation should meet all applicable regulatory, legal and billing compliance requirements

    In specific circumstances (e.g. emergencies, rapidly developing critical events, time sensitive
    sequential clinical care activities) an anesthesiologist or anesthesia care team member may be in
    conflict between a primary obligation to ensure patient safety and best clinical care, and
    contemporaneous medical record documentation. In these circumstances, attention to clinical care
    requirements remains the primary obligation. Medical record documentation should be provided as
    soon as appropriate in view of competing, primary clinical care requirements. The record should
    include documentation of:

    I. Preanesthesia Evaluation*

    A. Patient interview to assess:


    1. Patient and procedure identification
    2. Anticipated disposition
    3. Medical history – includes patient’s ability to give informed consent
    4. Surgical History (PSHx)
    5. Anesthetic history
    6. Current Medication List (preadmission and postadmission)

    1
    7. Allergies/Adverse Drug Reaction (including reaction type)
    8. NPO status
    9. Documenting the presence of and the perioperative plan for existing advance
    directives.

    B. Appropriate physical examination, including vital signs, height and weight and
    documentation of airway assessment and cardiopulmonary exam.

    C. Review of objective diagnostic data (e.g., laboratory, ECG, X-ray) and medical records.

    D. Medical consultations when applicable.

    E. Assignment of ASA physical status, including emergent status when applicable.

    F. The anesthetic plan – including plans for post-anesthesia care and pain management.

    G. Documentation of informed consent (to include risks, benefits and alternatives) of the
    anesthetic plan and postoperative pain management plan.

    H. Appropriate premedication and prophylactic antibiotic administrations (if indicated).

    II. Intraoperative/procedural anesthesia (time-based record of events)

    A. Immediately prior to the start of anesthesia care and anesthesia procedures:


    1. Patient re-evaluation
    2. Confirmation of availability of and appropriate function of all necessary
    equipment, medications and staff.

    B. Physiologic monitoring data** (e.g., recording of results from routine and nonroutine
    monitoring devices).

    C. Medications administered: dose, time, route, response (where appropriate).

    D. Intravenous fluids: type, volume and time.

    E. Technique(s) used.

    F. Patient positioning and actions to reduce the chance of adverse patient


    effects/complications related to positioning.

    G. Additional Procedures performed: vessel location, catheter type/size, specific insertion


    technique (e.g., sterile technique, use of ultrasound), actions to reduce the chance of related
    complications (ex., catheter based infection prevention measures), stabilization technique
    and dressing.

    2
    H. Unusual or noteworthy events during surgery and anesthesia care.

    I. Patient status at transfer of care to staff in a Postanesthesia Care Unit (PACU) or an area
    which provides equivalent postanesthesia care (e.g., ICU, SDS or floor nurse).

    III. Postanesthesia

    A. A time-based record of events that reflects the patient status on admission and discharge
    from the Postanesthesia Care Unit (PACU), as determined by a qualified anesthesia
    provider or by local departmental preset discharge protocols (i.e. postanesthesia note to be
    completed only when a patient is sufficiently recovered from acute administration of
    anesthesia and can participate in the evaluation) or admission to the intensive care unit.
    B. If the PACU is bypassed, criteria demonstrating that patient status at transfer of care are
    appropriate.

    C. It is not the responsibility of the anesthesiologist to document the patient’s condition


    throughout the PACU stay or when leaving the PACU.

    D. Significant or unexpected post-procedural events/complications.

    E. Postanesthesia evaluation documenting physiologic condition and presence/absence of


    anesthesia related complications or complaints.

    * See Basic Standards for Preanesthesia Care

    ** See Standards for Basic Anesthetic Monitoring

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