Anesthetic Records Flashcards
3 required records for anesthesia
- Controlled Drug Log
- Surgery and Anesthesia Log
- Medical Records
purpose of medical records
Complete and comprehensive medical records help to mitigate
risks to:
* the patient,
* the veterinarian, and
* the client
The medical record is the primary source that provides the necessary information to:
* ensure continuity of care,
* enable effective collaboration among the veterinary team, and
* demonstrate the quality of a veterinarian’s practice.
what is the governing body for legislation and standards of practice
CVO
what falls under the following acts:
- veterinarians act
- controlled drugs and substances act
Veterinarians Act: MRs, including anesthetic records
Controlled Drugs and Substances Act: controlled drug log
what is the purpose of the anesthetic record in anesthesia during and in the future
during:
- monitor physiological variables
- indicate need for adjustments in the protocol (ex. changes in inhalant concentration)
- indicate needs for additional treatment (ex. fluids therapy, inotropic drugs)
after:
- informs future anesthetic management
what is a major purpose of the anesthetic record for the team
can see trends to inform current and future practices and helps with communication of patient status to the team
what is a major purpose of the anesthetic record for the client
ensures standards of practice are maintained
what is included in the individual patients medical record and anesthesia (for in-hospital anesthesia)
-Preanesthetic evaluation (physical examination) and rationale for
sedation/anesthesia should be clear in the patient’s medical record
-Anesthetic Monitoring Chart (or Anesthetic Record)
-Postoperative Assessment
-Prescribing/dispensing information (if Applicable)
-Discharge Instructions (CA) or Care Instructions (Mobile-LA)
key features of the anesthetic record
- Owner Identification
- Patient Identification and signalment
- Veterinary team members
- Scheduled procedure
- Pre-surgical examination (including weight)
- Preoperative Status/ASA Status
- Baseline laboratory analysis if performed: example-PCV, TP, BUN
how do we record drug information on the anesthetic record
in QUANTITY (g, ug, or mg) as well the time of administration (exception being inhalants where we put the dialed %)
especially important to include the START and END of anesthesia
how do we record fluid therapy on the anesthetic record
1) total amount administered (volume)
2) rate over time of administration
what physiological variables are recorded on the anesthetic record and what is their code
-HR (.)
-RR (x)
-BP (systolic: v; diastolic: ^; mean: -)
temperature (at at least the beginning and end)
what is included in the post-anesthetic assessment
-pain scores
-physiological variables (includes MM colour and CRT)
-activity, concerns, etc
what is a recommendation if giving sedation
to monitor and record physiological variables, especially if heavy sedation or compromised animal
what provides the standards for patient medical records and facility records (2)
Veterinarians Act and Accreditation Standards for Veterinary Facilities
