Morgan & Mikhail Chap 18 (Preop Assess, Meds, Document)

Question 1

Preop Evaluation

Answer 1

Question 2

ASA and Risk

Answer 2

Question 3

ASA and Risk Chart

Answer 3

Question 4

Elements of Preop Hx: Cardio

Answer 4

Question 5

Elements of Preop Hx: Pulmonary

Answer 5

Question 6

Elements of Preop Hx: Endocrine and Metabolic Issues

Question 7

Elements of Preop Hx: Endocrine and Metabolic Issues

Answer 7

Question 8

Elements of Preop Hx: Coagulation Issues

Answer 8

Question 9

Elements of Preop Hx: Gastrointestinal Issues

Answer 9

Question 10

Elements to the PreOp Physical Exam: Airway

Answer 10

Question 11

PreOp Lab Testing

Answer 11

Question 12

Documentation

Answer 12

PreOp Note
In the United States, the Joint Commission (TJC) requires an immediate preanesthetic “reevaluation” to determine whether the patient’s status has changed in the
time since the preoperative evaluation was performed. This reevaluation might include a review of the medical record to search for any new laboratory results or consultation reports if the patient was last seen on another date. However, even when the elapsed time is less than a minute, the bureaucracy will not be denied: the “box” must be checked to document that there has been no interval change.

Intraoperative Anesthesia Record
The intraoperative anesthesia record serves many purposes. It functions as documentation of intraoperative monitoring, a reference for future anesthetics for that patient, and a source of data for quality assurance and billing. This record should be terse, pertinent, and accurate.
Unfortunately, the conventional, handwritten anesthetic record is ill suited for
documenting critical incidents, such as a cardiac arrest. In such cases, a separate text
note inserted in the patient’s medical record may be necessary.

Postoperative Note
Before discharge from the PACU, a note should be written by
an 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 18–4). Recovery from anesthesia should be assessed at least once within 48 h after discharge from the PACU in all inpatients

TABLE 18–4 Elements required by the Center for Medicare and Medicaid
Services in all postoperative notes:
Respiratory function, including respiratory rate, airway patency, and oxygen
saturation
Cardiovascular function, including pulse rate and blood pressure
Mental status
Temperature
Pain
Nausea and vomiting
Postoperative hydration