The Anesthesia Record is a Legal Document



The Anesthesia Record is a Legal Document


Joseph F. Talarico DO

David G. Metro MD

Renee A. Metal JD



In the unfortunate event that you are named in a lawsuit, the anesthesia record can be your best friend—or your worst enemy. Because the anesthesia record is the only document that is continuously and concurrently recorded during the course of surgery, the anesthesia record is often considered the most important document detailing occurrences in the operating room. The anesthesia record is used not only as a record of anesthesia management but also as one of medical and, to a degree, surgical management. For this reason, anesthesia providers must give considerable thought to the development of the anesthesia record as well as to its utilization. It is imperative that the anesthesia record be accurate, clear, and comprehensive regardless of the complexity of the case and regardless of whether complications occurred during the course of the case.


COMPONENTS OF THE ANESTHESIA RECORD

The anesthesia and operative record is the medical and ultimately legal document that records an anesthetic procedure. This record becomes part of the patient’s permanent medical record and should be as accurate and complete as possible. It provides information to other care providers that may influence the postoperative medical decision making for the management of the patient. All anesthesia providers involved in the delivery of care should sign the anesthesia record. All providers signing the chart should confirm the record’s accuracy, and it should include the information identified in Table 184.1. The old adage, “If it’s not on the chart, it never happened,” is not necessarily true (i.e., intravenous placement procedure does not need to be routinely documented in the absence of complications). It is, however, imperative that all significant occurrences be appropriately documented on the chart.

Although the components of the anesthesia record are virtually universal, there is considerable variation among institutions regarding the information to be included in the record: some records are all-inclusive, attempting to cover every aspect of anesthesia care (e.g., type of laryngoscope blade used, amount of air in endotracheal tube cuff, etc.), whereas others include little more than the minimum. Although there are legitimate opinions that
support both extremes, it is imperative that all sections of the anesthesia form that is in fact being utilized by the medical institution within which one is practicing be timely and entirely completed.









TABLE 184.1 COMPONENTS OF THE ANESTHESIA RECORD

























Patient information:


▪ Name


▪ Medical record number


▪ Age


▪ ASA physical status


Date
Location of anesthetic
Diagnosis and procedure
Attending and assisting:


▪ Anesthesia personnel


▪ Surgical personnel


Times:


▪ Anesthesia start


▪ Anesthesia end


▪ Surgical start


▪ Surgical end


Dosage and times or administration:


▪ Preoperative medication


▪ Anesthetic agents


▪ Other drugs


▪ IV fluids


▪ Blood and blood products


Pertinent events occurring during:


▪ Induction of anesthesia


▪ Maintenance of anesthesia


▪ Emergence from anesthesia


(This includes surgical as well as anesthetic “events”)


Pertinent lab results obtained during anesthetic


During the anesthetic, the following should be routinely monitored and recorded at the following intervals (at a minimum):


▪ Pulse (q 5 min)


▪ Blood pressure (q5min)


▪ Respiration (q15min)


▪ EKG rhythm (q15min)


▪ Pulse oximetry (q15min)


▪ End-tidal CO2 in intubated/ventilated patients (q15min)


▪ Tidal volume in intubated/ventilated patients (q15min)


▪ Peak airway pressures in positive-pressure ventilation (q15min)


▪ Temperature in patients at risk for hypo-/hyperthermia (q15min)


▪ Position of the patient and pressure-point issues


Patient’s vital signs on arrival to the recovery room


Either as part of the anesthetic record or on a separate cover, a preanesthetic evaluation should be documented including:


▪ NPO time


▪ Patient weight


▪ Pertinent past medical history


▪ Pertinent past surgical/anesthetic history


▪ Current medications


▪ Allergies


▪ Physical exam with at minimum




  • Airway exam



  • Cardiac exam



  • Pulmonary exam



  • Other pertinent exams


▪ Pertinent laboratory/study data


ASA, American Association of Anesthesiologists; IV, intravenous; EKG, electrocardiogram; NPO, nothing-by-mouth.


Jul 1, 2016 | Posted by in ANESTHESIA | Comments Off on The Anesthesia Record is a Legal Document
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