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Diastolic FAQ
Appropriate physical examination, including vital signs, height and weight and documentation of airway assessment and cardiopulmonary exam. Review of objective diagnostic data (e.g., laboratory, ECG, X-ray) and medical records. Medical consultations when applicable.
The anesthesia record provides information about detailed perioperative care, which includes preoperative assessment, anesthesia management, vital parameters, and intraoperative events. Accurate and complete anesthesia documentation is a must for the following reasons: to enable preanesthetic planning.
The anesthesiologist concludes the preoperative note by recording the type of anesthesia that will be provided: GA (general anesthesia), MAC (monitored anesthesia care), IV sedation, spinal, epidural, regional, IV bier, or others.
1. Anesthesia Start, Induction end, Surgical Incision, Surgical Complete, and Anes End should all be included where indicated. 2. Time of day should be recorded at 15-minute intervals during the procedure (use multiple anesthetic records if necessary).
The anesthesia record is a document that provides information about perioperative care. This provides data on preoperative assessment, anesthesia management, vital parameters, and intraoperative events.
Chart the Vitals Mean arterial blood pressure (X) and heart rate (•) should be charted every five minutes. Systolic and diastolic pressures should be charted every 15 minutes. The time and dose of antibiotics should also be charted. If surgeons request no antibiotics, make sure to chart "Not Indicated".
The anesthesia record is the main document of the intraoperative course of anesthesia administration. The chart is your legacy and the record of what happened many years after the occurrence of an incident. It can be your best ally or your worst enemy.
Jaw tone can also be used throughout anesthesia to assess anesthetic depth, as can the presence or absence of a withdrawal reflex (present only under a light plane of anesthesia). Cardiovascular status is typically assessed using mucous membrane color and capillary refill time.
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