Documentation the Anesthesia Record Carol Elliott, CRNA

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Documentation the Anesthesia RecordCarol
Elliott, CRNA
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First Anesthesia Record

• 1894 -Dr. Codman,
• Massachusetts General Hospital
• Heart rate and Pulse every 5 minutes
• Began record-keeping as a curiosity

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Purpose of the Record

• Basis for to anesthetic management
• Permanent documentary evidence of the anesthetic
  management

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Purpose of the Record (Cont 1 )

• Documentation of communication with the patient
  and personnel
• Protects the interests of the patient, hospital,
  and the anesthetist

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Purpose of Record (Cont 2)

• Provides account of care for QA, peer review and
  staff education
• Business record for billing
• Evidence of compliance with standards of care

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Purpose (cont 3)

• Directs patient care
• Administration / management
• Reimbursement

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Purpose ( cont 4)

• Research
• Serves to document adherence to Standards of
  Care

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Origins of Standards

• Professional organizations
• Governmental entities
• Employers
• Payers
• Department policies

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Standards of Care

• Standard I
• A thorough preoperative evaluation shall be
  performed
• Standard II
• Informed consent shall be obtained

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Standards of Care

• Standard III
• A patient specific plan shall be formulated
• Standard IV
• The plan shall be skillfully implemented and
  adjustments made as indicated

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Standards of Care

• Standard V
• The patients physiologic condition shall be
  continuously monitored
• Standard VI
• Information shall be promptly recorded

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Standards of Care

• Standard VII
• Responsibility for care shall be transferred in a
  manner that assures continuity of care
• Standard VIII
• Precautions shall be taken to assure equipment
  safety and minimize hazards

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Safe and Legal Care

• Record must reflect quality of care based on
  current practice standards
• Failure to document makes good care
  non-defensible in a court of law

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What to document

• Preoperative assessment
• Informed consent
• Equipment check
• Anesthetic management

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What to Document

• Transfer to recovery
• Postoperative note
• Untoward events

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Preoperative Documentation

• All patients must be assessed prior to surgery
• Assessment must be documented
• Shift to outpatient surgery makes assessment
  difficult

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Obtaining Information

• Personal interview is best
• Telephone interview
• Mail in questionnaire
• Interview by other personnel

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Information to Document

• Demographics
• Surgical history
• Age, Ht, Wt
• Baseline vital signs

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Documented Information (Contd)

• Physical assessment / system review
• Current medications
• Herbal Ingestion
• Allergies
• X-ray / ECG results
• Lab results

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Documented Information (Contd)

• Airway assessment / plan
• HIV / hepatitis risk factors
• Anesthetic history / complications
• Allergies
• ASA classification
• Informed consent

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Informed Consent

• Express written consent
• risks / benefits
• alternatives
• obtain for each procedure
• Implied consent
• Obtain prior to sedation

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Emergency Procedures

• Surgery must make entry in the progress note
• Case may proceed with patient in less than
  optimal condition
• Patient should be informed of risk

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Prior to Induction

• History / lab reviewed
• Machine / equipment checked
• Intravenous line started
• Sedation given in holding area
• Monitors Applied
• Time care started

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Intraoperative Documentation

• Baseline vital signs
• Anesthetic procedure
• Airway management
• Temperature

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Intraoperative Documentation (Contd)

• Intraoperative parameters
• vital signs
• ventilation / oxygenation
• circulation
• Induction drugs

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Intraoperative Documentation (Contd)

• Inhalation agents
• dial setting
• end tidal concentration
• Other drugs
• Fluids / blood loss
• Ventilatory parameters

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Intraoperative Documentation (Contd)

• Urine output
• Catheters / needles
• Neuromuscular blockade
• Note records are best when interventions are
  supported by other evidence on the record

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Documenting Regional Anesthesia

• note by a diamond ?
• Write narrative of the procedure
• note manufacturer and lot number
• Describe results of the procedure

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Documenting Emergence

• Agents turned off
• Relaxants reversed
• Extubation criteria
• sustained tetanus
• head lift
• responding to commands
• spontaneous ventilation

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Transfer to Recovery

• Level of consciousness
• Ventilatory status
• Vital signs / temp
• Report given (to whom)
• Drug / fluid totals
• Note transfer of care

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Postoperative Note

• Follow-up visit is required
• Note all complications
• Follow-up on any problems
• This is your chance to promote your profession.
  Take credit for your good work.

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Document Abnormal Situations

• Consultations
• Emergency blood use
• Physiologic alterations / treatments
• Unusual occurrences
• Code situations

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Correcting Errors

• Draw single line through incorrect entry
• Bad entry must be legible
• Correct the error
• Date, time and initial correct entry
• Never erase or use white out

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Automated Anesthesia Record-keeping

• Advantages
• continuous record of all monitored parameters
• provider can focus on the patient
• continues at times when the patient requires 100
  of the providers attention

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AUTOMATED RECORDS

• Advantages (Contd)
• records exactly what is displayed on the monitor
• Guaranteed to be legible

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Automated Records

• Disadvantages
• may actually reduce vigilance
• item entry may distract provider from the patient
• provider must be comfortable with computers
• artifacts may appear on the record
• medical/legal implications are untested

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Other uses for Automation

• Billing and collection
• may pay for itself in recovery of uncharged items
• Facilitates QA program
• Facilitates research
• May be linked to other patient information

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Effective Documentation

• Is timely and legible
• Documents that standard of care was met
• Correlates with other accounts of the surgical
  procedure
• Avoids smothered data