A Health Information Management (HIM) / Medical Records (MR) practitioner will find documentation of preoperative activities including each patient’s anaesthesia care which is planned and documented in the patient’s record.
The Joint Commission International (JCI) Standard ASC.5 specifically requires documentation of preoperative activities to include that each patient’s anaesthesia care is planned and documented in the patient’s medical record.
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.
After the preoperative evaluation by an anaesthesiologist or another qualified individual as outlined in the post Anesthesia care must be given by a qualified individual (this link will open in a new tab of your current window), anaesthesia care is carefully planned and the anaesthesia plan is created,
The plan includes a list of drug choices and doses in detail, the method of administration, other medications and fluids, monitoring procedures, and anticipated postanesthesia care.
An HIM) / MR practitioner will find documentation of each patient’s anaesthesia care plan as shown in the sample General Anaesthesia Plan below documented in the patient’s medical record.
SAMPLE GENERAL ANAESTHESIA PLAN
Case
A 47-year-old woman with biliary colic and well-controlled asthma requires anaesthesia for laparoscopic cholecystectomy.
Preoperative Phase
Premedication
Midazolam, 1-2 mg IV, to reduce anxiety
Albuterol, two puffs, to prevent bronchospasm
Intraoperative Phase
Vascular access and monitoring
Vascular access: one peripheral IV catheter
Monitors: pulse oximetry, capnography, electrocardiogram, non-invasive blood pressure with standard adult cuff size, temperature
Induction
Propofol, 2 mg/kg IV (may precede with lidocaine, 1.5 mg/kg IV)
Neuromuscular blocking drug to facilitate tracheal intubation (succinylcholine, 1-2 mg/kg IV) or nondepolarizing neuromuscular-blocking drugs (rocuronium, 0.6 mg/kg)
Airway management
Facemask: adult medium size
Direct laryngoscopy: Macintosh 3 blade, 7.0-ID endotracheal tube
Maintenance
Inhaled aesthetic: sevoflurane or desflurane
Opioid-fentanyl: anticipate 2-4 mg/kg IV total during case
Neuromuscular blocking drug titrated to train-of-four monitor (peripheral nerve stimulator) at the ulnar nerve*
Emergence
Antagonize effects of nondepolarizing neuromuscular blocking drug: neostigmine, 70 mg/kg, and glycopyrrolate, 14 mg/kg IV, titrated to train-of-four monitor
Antiemetic: dexamethasone, 4 mg IV, at start of case; ondansetron, 4 mg IV, at end of case
Tracheal extubation: when patient is awake, breathing, and following commands
Possible intraoperative problem and approach
Bronchospasm: increase inspired oxygen and inhaled aesthetic concentrations, decrease surgical stimulation if possible, administer albuterol through endotracheal tube (5-10 puffs), adjust ventilator to maximize expiratory flow
Postoperative Phase
Postoperative pain control: patient-controlled analgesia – hydromorphone, 0.2 mg IV; 6-minute lock-out, no basal rate
Disposition: postanesthesia care unit, then hospital ward*Nondepolarizing neuromuscular blocking drug choices include rocuronium, vecuronium, pancuronium, atracurium, and cisatracurium.
*Nondepolarizing neuromuscular blocking drug choices include rocuronium, vecuronium, pancuronium, atracurium, and cisatracurium.
Source : Ronald DM & Manuel CP Jr 2011, Basics Of Anaesthesia, 6th edn, Elsevier Saunders, Philadelphia, PA, USA
Do take note that sometime the anaesthesia plan may require modification of the plan which may include a specific requirement for an individual patient and thus may have implications for preparing additional equipment in the operating room for example, special equipment that may be kept in a cart dedicated to difficult airway management or in another instance, the patient’s responses to anaesthesia and surgery may also cause the anaesthesia plan to be adjusted.
When each patient’s anaesthesia care is planned and documented in the patient’s record, then you can be sure that medical record fully meets the two requirements of JCI Standard ASC.5
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 Anaesthesia, 6th edn, Elsevier Saunders, Philadelphia, PA, USA
