The patient undergoes preoperative nursing assessment (screening), and receives preanesthesia evaluation by an anaesthesiologist to place the patient in the best possible condition for surgery through careful assessment and thorough preparation. Assessment of the patient’s status before surgery establishes baseline data to direct interventions throughout the perioperative phases (the peroperative phase is a phase of the three perioperative phases).
Because anaesthesia carries a high level of risk, a qualified individual must conduct a preanesthesia assessment and preinduction assessment for each patient. For example (Ronald & Manuel, 2011), a patient undergoing coronary artery bypass graft has a significant risk of problems such as death, stroke, or myocardial infarction. A patient undergoing cataract extraction has a low risk of major organ damage.
An anaesthesiologist or certified Registered Nurse Anaesthetist (RNA) are two qualified anaesthesia providers who actively participate in conducting a preanesthesia assessment and preinduction assessment for each patient.
The main role of the anaesthesiologist or RNA is to ensure patient safety relative to the administration of anaesthesia. The anaesthesia provider:
- Obtains informed consent for anaesthesia services
- Performs a preanesthesia assessment that includes a thorough history, such as complications from previous anaesthesia, and physical examination
- Selects anesthetic agents
The patient’s preanesthesia assessment is for the use of postoperative analgesia. The preanesthesia assessment may be carried out some time prior to admission or prior to the surgical procedure or shortly before the surgical procedure, as in emergency and obstetrical patients.
Medical records from previous surgeries are reviewed when appropriate and feasible as part of the preanesthesia examination.
A separate preinduction assessment is performed to re-evaluate patients immediately before the induction of anaesthesia. Assessment evaluates if the patient has coexisting medical problems and if the surgery or anaesthesia care plan needs to be modified because of them. To anticipate the effects of a given medical problem, the anaesthesia provider then focuses on the patient’s physiologic stability from the physiologic effects of the surgery and aesthetic, and readiness of the patient for anaesthesia and occurs immediately prior to the induction of anaesthesia. For example, the anaesthesia provider may change (Ronald & Manuel, 2011) the anaesthetic plan to increase the induction dose of intravenous anaesthetic for a patient with poorly controlled systemic hypertension who is more likely to have an exaggerated hypertensive response to direct laryngoscopy to facilitate tracheal intubation.
When anaesthesia must be provided emergently, the preanesthesia assessment and preinduction assessment may be performed immediately following one another, or simultaneously, but are documented independently. The urgency (Ronald & Manuel, 2011) of a given procedure (e.g., acute appendicitis) may preclude lengthy delay of the surgery for additional testing, without increasing the risk of complications (e.g., appendiceal rupture, peritonitis).
The Joint Commission International (JCI) Standard ASC.4 requires documentation in a medical record for a preanesthesia assessment and a separate preinduction assessment performed to re-evaluate patients immediately before the induction of anaesthesia by “A qualified individual” who “conducts a preanesthesia assessment and preinduction assessment.” for every patient prior to surgery.
An Health Information Management (HIM) / Medical Records (MR) practitioner will find documentation of preoperative activities including preanesthesia assessment using the preoperative checklist and a separate preinduction assessment always entered in the patient’s medical record on the appropriate forms. This is true for all patients in the preoperative phase in all hospitals, and not just for hospitals already JCI accredited or seeking JCI or other healthcare quality standards.
The preoperative checklist is used to document accurate completion of preoperative activities, including preanesthetic evaluation done (using the preanesthesia evaluation note). This checklist identifies assessments, medications, and other physical preparations that must be completed before the client is anesthetised.
The preanesthesia evaluation note is a progress note (Michelle & Mary, 2011) documented by any individual qualified to administer anaesthesia prior to the induction of anaesthesia. Includes evidence of patient interview to verify past and present medical and drug history and previous anaesthesia experience(s), evaluation of the patient’s physical status, review of the results of relevant diagnostic studies, discussion of preanesthesia medications and choice of anaesthesia to be administered, surgical and/or obstetrical procedure to be performed, and potential anaesthetic problems and risks; sometimes documented on a special form located on the reverse of the anaesthesia record.
An anaesthesia record is required to show preanesthesia medication administered, including time, dosage, and effect on patient, when a patient receives an anaesthetic other than a local anaesthetic.
Preanesthesia (and postanesthesia) evaluation progress notes are sometimes documented on a special form located on the reverse side of the anaesthesia record. This can prove helpful to anaesthesiologists so that no documentation elements are forgotten.
The preanesthesia progress notes and anaesthesia record provide the documentation of the administration of preoperative medications, and evaluation of the patient preoperatively in the medical record. The medical record of a patient must show evidence of a preanesthesia assessment and a separate preinduction assessment that was performed to re-evaluate the patient immediately before the induction of anaesthesia, both of which were conducted by an individual(s) qualified to do so. Such aforementioned evidence meets JCI requirements.
References:
Joint Commission International 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
Michelle AG & Mary JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, Delmar, Cengage Learning, NY, USA
Ronald DM & Manuel CP Jr 2011, Basics Of Anesthesia, 6th edn, Elsevier Saunders, Philadelphia, PA, USA
Sue, CD & Patricia, KL 2011, Fundamentals of Nursing: Standards & Practice, 4th edn, Delmar, Cengage Learning, NY, USA
