Exam 1 Lecture 1 Flashcards
H+P is good for
30 days
Preoperative evaluation is good for
30 days
3 components of anesthesia record
- pre-anesthetic evaluation
- intra-anesthetic record
- postoperative
pre-anesthetic evaluation ends with
attainment of informed consent
intra anesthetic record consists of
-evidence of continuous observation of the patient
induction
maintenance
emergence
Critical step in delivery of anesthesia care
planning
issues in manual charting
smoothing
batch recording
soiled records
misplacement/loss
Smoothing
smooth out the record, not all inclusive, goal = railroad tracks
Batch recording
too busy, fill out all at once when you have time
concerns re: computerized charting
liability, cost, confidentiality, more equipment
Elements of informed consent
- disclosure of information
- comprehension
- voluntary
- capacity to consent
purpose of informed consent
educate + protect the patient (+ provider)
components of disclosure of information (informed consent)
- purpose/rationale of proposed anesthetic technique
- risks, benefit, alternatives
unauthorized touching
common law battery
provider fails to warn of risks or instruct of alternatives
negligence
OB anesthesia: providers legal obligation is to ____
mother
legal authority to consent
competence
ability to decide
capacity
Physical status classification
ASA classification system
Physical status classification: Class 1
healthy w/ good exercise tolerance
Physical status classification: Class 2
no functional limitations
well-controlled disease of 1 body system
(DM, HTN, mild obesity, pregnancy, smoker)
Physical status classification: Class 3
Some fxnal limitation
controlled dx of 2+ body system
i.e. CHF, stable angina, old heart attack, poorly controlled HTN, morbid obesity, chronic renal failure, bronchospastic dx w/ intermt s/s
Physical status classification: Class 4
Severe systemic disturbance
-poorly controlled/end stage
life threatening w/ or w/o surgery
Physical status classification: Class 5
moribund patient: surgery = last resort
