Documentation

Documentation

Recording information on the anesthesia record is important. The anesthesia provider is responsible for the patient from the time they enter the operating room through the recovery period. Maintaining a continuous record will help the anesthesia provider remain vigilant during the case. A well documented anesthesia record is useful for future anesthetics, guiding care of the patient. It serves to document anesthetic technique and complications that may have been encountered during the anesthesia time. Documentation should be neat and legible. Anesthesia records differ from practice to practice.

Pre-Anesthesia Evaluation Documentation

The first item that is documented is identification of the patient. This will ensure that the pre-anesthesia workup does not get confused with another patient. The date of surgery, patient name, proposed surgical procedure, name of the surgeon, family contact, name of the anesthesia provider, city or village, ward or bed number, height, weight, and pre-operative vital signs should be documented. Review the patient's laboratory values and document the results. You have to record the history, physical examination of the body system, your findings, ASA classification, Mallampati air way grade and other relevant information must be included in your preanesthetic form