Get Printable Anesthesia Record Template 2020-2025

Medical history – includes patient's ability to give informed consent. Surgical History (PSHx) Anesthetic history. Current Medication List (preadmission and postadmission)

Anesthesia documentation represents a detailed account of the patient's anesthesia care during various phases of anesthesia, including preanesthesia assessment and evaluation, informed consent, anesthesia services, and postanesthesia care.

In ance with the ASA Guidelines, “An anesthesiologist shall be responsible for determining the medical status of the patient and developing a plan of anesthesia care.” The Center for Medicare & Medicaid Services (CMS) requires that a medically directing anesthesiologist sign the pre-anesthesia documentation.

Patient interview to assess: Patient and procedure identification. Anticipated disposition. Medical history – includes patient's ability to give informed consent. Surgical History (PSHx) Anesthetic history. Current Medication List (preadmission and postadmission) Allergies/Adverse Drug Reaction (including reaction type)

The services include the usual preoperative and postoperative visits, anesthesia care during the procedure, the administration of fluids and/or blood, and the usual monitoring services (such as electrocardiogram [ECG], temperature, blood pressure, oximetry, capnography and mass spectrometry).

The basic components of the anesthetic record sheet include patient-related data, preoperative assessment, provider information, anesthetics drugs and monitors, anesthetic techniques, perioperative vital signs, postoperative orders, and patient outcomes [[5], [6], [7], [8], [9], [10]].

The medical record should include evidence of continuous monitoring of the patient's oxygenation, ventilation, circulation and temperature. The medical record should include a post-anesthesia evaluation of the patient including any unusual events or complications and the patient's status on discharge.

Anesthesiologists evaluate, monitor, and supervise patient care before, during, and after surgery, delivering anesthesia, leading the Anesthesia Care Team, and ensuring optimal patient safety. Anesthesiologists specialize in anesthesia care, pain management, and critical care medicine.

Monitor patients before, during, and after anesthesia and counteract adverse reactions or complications as necessary. Process paperwork and ensure compliance with HIPPA regulations.