Chapter: Clinical Cases in Anesthesia : Office-Based Anesthesia

Are there any differences in record keeping or documentation as compared with the hospital setting?

Documentation in the office setting should be identical to that in a hospital. An appropriate preanesthesia evaluation and physical examination by an anesthesiologist is essential.

Are there any differences in record keeping or documentation as compared with the hospital setting?

Documentation in the office setting should be identical to that in a hospital. An appropriate preanesthesia evaluation and physical examination by an anesthesiologist is essential. If nonphysician personnel conducted the evaluation, it should be reviewed by the anesthesiologist and the infor-mation verified. Key elements of the evaluation should be documented. The anesthetic plan must be documented, as well as the discussion with and acceptance of the plan by the patient. An intraoperative and postoperative record must also be maintained. Confidentiality should be maintained.

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Clinical Cases in Anesthesia : Office-Based Anesthesia : Are there any differences in record keeping or documentation as compared with the hospital setting? |