Wiki Anesthesia documentation

[JCampbell]

Can anyone tell me what the requirements are for anesthesia documentation?

Thanks!

 

[mcnaryk]

Can anyone tell me what the requirements are for anesthesia documentation?

Thanks!

That's a pretty broad question, but I'll try to give you the basics: patient name, DOB, operating surgeon, and anesthesiologist and/or CRNA on case. Diagnosis, and operation/procedure done, mode of anesthesia (general, epidural, MAC). Anesthesia start and stop times, as well as surgery start and stop times. Physical status modifier (set by the anesthesia staff-coders CANNOT choose this). All of this information should be on the anesthesia record, and there should be a place on that record to indicate if any additional services were done, like ART or CVP lines or post-operative pain injections. There may also be a pre and post anesthesia evaluation in the patient's chart.