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There are four main categories of anesthesia used during surgery and other procedures: general anesthesia, regional anesthesia, sedation (sometimes called "monitored anesthesia care"), and local anesthesia. Sometimes patients may choose which type of anesthesia will be used.

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.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232