Anesthesia Charting Flashcards
(45 cards)
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)
