2. THE ANESTHESIA RECORD - PRACTICE PARAMETERS FOR DOCUMENTATION OF ANESTHESIA CARE.
Documentation is a factor in the provision of quality care. The final responsibility for the record rests with the physician responsible for anesthesia care. Anesthesia is usually viewed as consisting of preanesthesia, perianesthesia, and postanesthesia components. Anesthesia care should be documented to reflect these components and to facilitate review. The anesthetic record should be easily interpreted and use abbreviations that are widely accepted. The record should include documentation of all of the following subsections A through C:
A. Preanesthesia Evaluation
(1) Review of medical record, including:
(a) Pertinent objective diagnostic data (e.g. lab, EKG, chest x-rays).
(b) Old chart review of previous anesthetics when available and pertinent; and,
(2) Patient interview including history of:
(a) Medications
(b) Allergies
(c) Previous anesthetic experiences
(d) Family history of anesthesia problems, and,
(e) Pertinent review of systems;
(3) Physical exam appropriate to anesthesia care and special notation of airway in respect of dentition;
(4) ASA Physical status; and,
(5) Formulation and discussion of an anesthesia plan with the patient and/or responsible adult, including consent to that plan.
B. Perianesthesia
(1) Review immediately prior to initiation of anesthetic procedure:
(a) Record
(b) Patient reevaluation
(c) Check of equipment, drugs, and gas supply
(2) Monitoring of the patient as described in monitoring standards Section 3, following.
(3) Comment on airway management
(4) Amounts of all drugs and agents used, and times given
(5) Patient position and protection
(6) Management of fluids
(a) IV fluids used including blood products
(b) Estimated blood loss
(c) Urine output when appropriate
(7) The technique(s) used
(8) Unusual events during the anesthesia period
(9) The status of the patient at the conclusion of anesthesia
C. Postanesthesia.
(1) Patient evaluation on admission and discharge from the postanesthesia care unit.
(2) A time based record of vital signs and level of consciousness.
(3) All drugs administered and their dosages.
(4) Type and amount of intravenous fluids administered including blood and blood products.
(5) Any unusual events including postanesthesia or postprocedural complications.
(6) Medical interventions.
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