anesthesia

katysuegood@gmail.com

I have a meeting next week with anesthesia regarding documentation. In general, I dont see much documentation from anesthesia in my reviews.
Any ideas on focus?

Thanks,
Katy

Unknown

I'd concentrate on thorough history and assessment.

I've noticed that anesthesia does a fairly compressive assessment. For 'healthy' surgeries surgeons documentation is sparse (surgeon uses a checklist or only addresses the issue at hand). SDx can be picked up from anesthesia notes.

Often I notice the anesthesia notes will list diagnoses along with meds taken (very helpful for SDx)

Their op notes will also include what happens during OR (b/p drop, drips hung etc.). These tips can be used to query attending/surgeon for diagnosis.


Charlene

dbutler

Charlene makes several good points.

Anesthesia can be very helpful if they also indicate the diagnosis along with the treatment given intraoperatively.

Another area that they can be helpful is to document how pt's BMI/body habitus affects anesthesia care -- concern for difficult airway management or ventilation with morbid obesity for example. Can help to support that dx from a clinical perspective also.

We also sometimes find the only documentation of an ODX in anesthesia histories.

Their follow up notes can also be helpful.

Don

clungrin

ODX...that is a new one. Is that an appropriate abbreviation???