Anesthesia Charting Flashcards
Basic elements of chart?
Who, what, where, when, why
Patient, surgeon, CAA, AAS, Anesthesiologist Procedure Location of procedure Date Diagnosis
Benefits of electronic charting?
- Quality assurance
- No handwriting issues
- Frees up provider
- More accurate clinical documentation
- Research based practice
- Less time on documenting, more on patient care
Cons of electronic charting?
- Artifacts
- Obstruction of workflow
- Increase in litigation
- Continual IT support
- Gaps in monitoring cannot be “smoothed”
- Difficult integration of existing records with AIMS
Three pillars of documentation
- Legibility
- Consistency
- Accuracy
Joint commission “do not use” list
U, u (unit) IU (International unit) Q.D., QD, q.d., qd (daily) Q.O.D., QOD, q.o.d., qod (every other day) Trailing zero (Write X mg) Lack of leading zero (Write 0.X mg) MS (Write morphine sulfate) MS04 and MgSO4 (Write magnesium sulfate)
< and > No abbreviations for drug names Apothecary units The symbol @ The abbreviation cc (use mL instead) The abbreviation ug (use mcg instead)
How long from preoperative anesthesia assessment to time patient arrives for surgery must be no longer than what?
48 hours
T or F. Immediately upon entering the OR the patients vitals must be taken and documented?
True
Documentation of intraoperative care?
- Immediate review prior to anesthesia procedures
- Patient re-verification of NPO status
- Check of equipment, drugs and gas supply - Monitoring of the patient
- recording of vital signs and use of any non-routine monitors - Doses of drugs, agents used, and time and routes of administration as well as reaction to the drugs
- Type and amounts of IV fluids, blood and blood products, and times of administration
- Technique used and patient position
- IV/intravascular lines and airway devices that are inserted including technique for insertion and location
- Unusual events during administration of anesthesia
- Status of patient at the conclusion of anesthesia
Every 15 min check the following:
Pressure points, ECG rhythm rate, sinus rate (SR), UO (empty bag record how much is in it), estimated blood loss (EBL), IV (amount, type, duration), blood saturation (0-100%), etCO2 mmHg
Continual monitors?
Ex. blood pressure, CO2
Repeated regularly and frequently in steady rapid succession
Continuous monitors?
Ex. Ekg, capnograph, CO2 (monitored)
Prolonged without any interruption at any time
ASA Standard 1
Qualified anesthesia personal should be present in the room throughout the conduct of all general anesthesia, regional anesthesia and MAC
ASA Standard 2
During all anesthesia, the patients oxygenation, ventilation, circulation, and temperature shall be continually evaluated
Where do the charts go after they leave your hands?
Billing and quality assurance (QA)
AQI
Anesthesia quality institute
MPOG
Multicenter perioperative outcomes group
1 Unit is about how much?
$50-60
00148?
Anesthesia for procedures on eye; opthalmoscopy (4 units)
00120?
Anes-proc external middle & inner ear incl bx
00140?
Anesthesia for procedures on eye (5 units)
00216?
Anes-intracran; vascular procedures (15 units)
ASA classification 1 (Modifiers)
Normal healthy patient (0)
ASA classification 2 (Modifiers)
Patient with mild systemic disease (0)
ASA classification 3 (Modifiers)
Patient with severe systemic disease (1)
ASA classification 4 (Modifiers)
Patient with severe systemic disease that is a constant life threat (2)
ASA classification 5 (Modifiers)
Moribund patient not expected to survive w/out operation (3)
When does the time start on your chart?
The moment you are in constant care of the patient until you run over care to PACU, ICU
Other modifiers?
99100 - Anesthesia for patients of extreme age, under 1 year and over 70 (1 unit)
99116 - Anesthesia complicated by utilization of total body hypothermia (5 units)
99135 - Anesthesia complicated by utilization of controlled hypotnesion (5 units)
99140 - Anesthesia complicated by emergency conditions (2 units)
Deleting data?
Never do, never black out anything. Always strike through the text with black ink so it is still visible and initial it - record what was actually done
T or F. Only record medication administration if different than IV
True
Intraoperative, blood pressure and pulse measurements at what intervals? Other vitals?
Every 5 min, every 15 min
Write what vent settings every 30 min?
Vt, RR, PIP
Charting a drug in following order?
Drug, dose, route, time
T or F. Always write vitals before drugs
True
8 point check at end of case?
- Correct date
- Start time/end time
- Abx with correct dose/time
- AA signature
- Sevoflurane turned off, O2 flows up
- PACU vitals
- Fluid/EBL/Urine totals
- Opioid dose adds up with waste sheet
Preop vitals?
HR, BP, RR (write SV or CV), Sp02
PACU vitals?
HR, RR, BP, Sp02, T
7 things on Sheet 2 (Face Sheet)
- Date
- Procedure
- Initials of anesthesia providers
- Type of anesthesia
- ASA
- Surgeon
- Start time-End time
Sheet 3
Anesthesia charge sheet
Sheet 4
Pharmacy charge sheet
- Charge Abx only if they weren’t started prop
- Charge for each fluid bag we take out of our drawer (not from preop)
- Don’t forget to charge for stuff that isn’t included on the charge sheet (ex. LTA kit) write on extra blank spaces
Sheet 5
SCIP core measures sheet
-Basic checklist for every case
Sheets 6-8
Not anesthesia!
Sheet 6
QA sheet, filled out by hospital in adverse event
Sheet 7
Physician order sheet, anesthesiologist must sign after each case
Sheet 8
Patients medication list, originally stapled to OR record
