Documentation - Clinical Anesthesiology

DOCUMENTATION

Physicians should first and foremost provide high-quality and efficient medical care. Secondly, they must document the care that has been provided. Adequate documentation provides guidance to those who may encounter the patient in the future. It permits others to assess the quality of the care that was given and to provide risk adjustment of outcomes. Adequate documentation is required for a physician to submit a bill for his or her services. Finally, adequate and well-organized documenta-tion (as opposed to inadequate and sloppy docu-mentation) supports a potential defense case should a claim for medical malpractice be filed.

Preoperative Assessment Note

The preoperative assessment note should appear in the patient’s permanent medical record and should describe pertinent findings, including the medical history, anesthetic history, current medications (and whether they were taken on the day of surgery), physical examination, ASA physical status class, laboratory results, interpretation of imaging, electro-cardiograms, and recommendations of any consul-tants. A comment is particularly important when the consultant’s recommendation will not be followed. As most North American hospitals are transitioning to electronic medical records, the preanesthetic note will often appear as a standardized form.

The preoperative note should briefly describe the anesthetic plan and include a statement regard-ing informed consent from the patient (or guardian). The plan should indicate whether regional or general anesthesia (or sedation) will be used, and whether invasive monitoring or other advanced techniques will be employed. Documentation of the informed consent discussion sometimes takes the form of a narrative indicating that the plan, alternative plans, and their advantages and disadvantages (including their relative risks) were presented, understood, and accepted by the patient. Alternatively, the patient may be asked to sign a special anesthesia consent form that contains the same information. A sample pre-anesthetic report form is illustrated in Figure 18–1.

In the United States, The Joint Commission (TJC) requires an immediate preanesthetic reevalu-ation to determine whether the patient’s status has changed in the time since the preoperative evalu-ation was performed. Even when the elapsed time is less than a minute, the bureaucracy will not be denied: the “box” must be checked to indicate that there has been no interval change.

Intraoperative Anesthesia Record

The intraoperative anesthesia record (Figure 18–2) serves many purposes. It functions as documenta-tion of intraoperative monitoring, a reference for future anesthetics for that patient, and a source of data for quality assurance. This record should be terse, pertinent, and accurate. Increasingly, parts of the anesthesia record are generated automati-cally and recorded electronically. Such anesthe-sia information management systems (commonly abbreviated AIMS) have many theoretical and practical advantages over the traditional paper record but also introduce all the common pitfalls of

computerization, including the potential for unrec-ognized recording of artifactual data, the possibility that practitioners will find attending to the com-puter more interesting than attending to the patient, and the inevitable occurrence of device and software shutdowns. Regardless of whether the record is on paper or electronic it should document the anes-thetic care in the operating room by including the following elements:

            Whether there has been a preoperative check of the anesthesia machine and other relevant equipment.

·        Whether there has been a reevaluation of the patient immediately prior to induction of anesthesia (a TJC requirement); this generally includes a review of the medical record to search for any new laboratory results or consultation reports.

·        Time of administration, dosage, and route of drugs given intraoperatively.

·        Intraoperative estimates of blood loss and urinary output.

·        Results of laboratory tests obtained during the operation.

·        Intravenous fluids and any blood products administered.

·        Pertinent procedure notes (such as for tracheal intubation or insertion of invasive monitors).

·        A notation regarding specialized intraoperative techniques such as the mode of ventilation, or special techniques such as the use of hypotensive anesthesia, one-lung ventilation, high-frequency jet ventilation, or cardiopulmonary bypass.

·        Timing and conduct of intraoperative events such as induction, positioning, surgical incision, and extubation.

·        Unusual events or complications (eg, arrhythmias).

·        Condition of the patient at the time of release to the postanesthesia or intensive care unit nurse.

By tradition and convention (and, in the United States, according to practice guidelines) arterialblood pressure and heart rate are recorded graphi-cally no less frequently than at 5-min intervals. Data from other monitors are also usually entered graphi-cally, whereas descriptions of techniques or compli-cations are described in text. In some anesthetizing locations of most hospitals the computerized AIMS will be unavailable. Unfortunately, the conventional, handwritten intraoperative anesthetic record often proves inadequate for documenting critical inci-dents, such as a cardiac arrest. In such cases, a sepa-rate text note inserted in the patient’s medical record may be necessary. Careful recording of the timing of events is needed to avoid discrepancies between multiple simultaneous records (anesthesia record, nurses’ notes, cardiopulmonary resuscitation record, and other physicians’ entries in the medical record). Such discrepancies are frequently targeted by mal-practice attorneys as evidence of incompetence,inaccuracy, or deceit. Incomplete, inaccurate, or illegible records unnecessarily complicatedefending a physician against otherwise unjustified allegations of malpractice.

Postoperative Notes

The anesthesiologist’s immediate responsibility to the patient does not end until the patient has recov-ered from the effects of the anesthetic. After accom-panying the patient to the postanesthesia care unit (PACU), the anesthesiologist should remain with the patient until normal vital signs have been measured and the patient’s condition is deemed stable. Before discharge from the PACU, a note should be written by the anesthesiologist to document the patient’s recovery from anesthesia, any apparent anesthesia-related complications, the immediate postoperative condition of the patient, and the patient’s disposition (discharge to an outpatient area, an inpatient ward, an intensive care unit, or home). In the United States, as of 2009, the Centers for Medicare and Medicaid Services require that certain elements be included in all postoperative notes ( Table 18–3). Recovery from anesthesia should be assessed at least once within 48 h after discharge from the PACU in all inpatients. Postoperative notes should document the general condition of the patient, the presence or absence of any anesthesia-related complications, and any mea-sures undertaken to treat such complications.