The decision-making process necessary for deciding which anaesthesia to use and the anaesthetic technique to select is the responsibility of the anaesthesiologist, the anaesthesia provider (the health professional providing the care) rendering the anaesthetic care planned for the patient related to his or her identified needs.
The anaesthesia care provider has several options deciding which anaesthetic technique (Ronald & Manuel 2011) to select available including (1) general anaesthetic – usually induced in adult patients by the intravenous administration of an anaesthetic (propofol, thiopental, or etomidate) that produces rapid onset of unconsciousness, (2) regional anaesthetic – spinal (Spinal anaesthesia is accomplished by injecting local anaesthetic solution into the cerebrospinal fluid (CSF) contained within the subarachnoid (intrathecal) space. or epidural (achieved by injection of local anaesthetic solution into the space that lies within the vertebral canal but outside or superficial to the dural sac) or caudal anaesthesia (represents a special type of epidural anaesthesia in which local anaesthetic solution is injected into the caudal epidural space through a needle introduced through the sacral hiatus) are selected when maintenance of consciousness during surgery is desirable, (3) peripheral nerve block – a technique of anaesthesia for superficial operations on the extremities or (4) monitored anaesthetic care (MAC) – a procedure in which an anaesthetic provider is requested or required to provide anaesthetic services, which include preoperative evaluation, care during the procedure, and management after the procedure.
I shall avoid details of the types of the anaesthesia used and the anaesthetic techniques (I have already given enough extracted text-book explanations in the paragraph above of anaesthetic techniques) used. as I think it is only appropriate for me to highlight in this post what needs to be satisfied by a quality assurance requirement, for example the Joint Commission International (JCI) quality Standard ASC.5.2 which requires that “The anaesthesia used and aesthetic technique are written in the patient record.”
It is clear from the intent of this standard that JCI surveyors must be able to find evidence of the anaesthesia used and anaesthetic technique written somewhere in the patient’s medical record during a hospital survey process. The Health Information Management (HIM) / Medical Records (MR) practitioner’s role should be ensure that he or she can identify the location of this evidence in the medical record and contribute to completeness and quality of the medical record.
Anaesthesia providers qualified to administer anaesthesia like an anaesthesiologist, documents patient monitoring when a patient receives an anaesthetic other than a local and other activities related to the surgical episode. Detailed records of the course of anaesthesia are documented in an anaesthesia record, the piece of evidence of the anaesthesia used and anaesthetic techniques used. Preoperative and postoperative visits, and detailed records of the course of anaesthesia, serve as the best protection for the anaesthesiologist or other authorised anaesthetic provider against medico legal action.
Contents of the anaesthesia record in the usual handwritten anaesthetic record documenting the anaesthesia used and the anaesthetic technique used contain adequate information (Michelle & Mary 2011) and justify the anaesthesia care as follows:
- Preanesthesia medication administered, including time, dosage, and effect on patient
- Appraisal of any changes in the patient’s condition (since preanesthesia evaluation)
- Anaesthesia agent administered, including amount, technique(s) used, effect on patient, and duration, qualifying for full compliance against ME 1 and ME 2 requirements for JCI Standard ASC.5.2
- Patient’s vital signs (e.g., temperature, pulse, blood pressure)
- Any blood loss
- Transfusions administered, including dosage and duration IV fluids administered, including dosage and duration
- Patient’s condition throughout surgery, including pertinent or unusual events during induction of, maintenance of, and emergence from anaesthesia.
- Authentication by the individual qualified to administer anaesthesia (e.g., certified registered nurse anaesthetist, anaesthesiologist) and names of anaesthesia assistants identified in the patient’s anesthesia record, would then serve to satisfy full compliance with the ME 3 for Standard ASC.5.2
Here is a part of an anaesthesia record (as below) showing the fields for recording anaesthetic technique and anaesthesia agents used (click on the image for a larger view in a new tab of your current browser window).
Source :Michelle, AG & Mary, JB 2011, Essentials of Health Information Management: Principles and Practices, 2nd edn, pg 163
Do take note that preanaesthesia and postanaesthesia evaluation progress notes are sometimes documented on a special form located on the reverse side of the anaesthesia record.
HIM/MR practitioners should also ensure that the medical record contains all records of previous admissions. This is important when an anaesthesia record of a previous surgery which contains historical information, could yield much useful information for the anaesthesia provider especially in the ease of airway management techniques such as direct laryngoscopy when the physical examination by the anaesthesia provider suggests some risk factors for difficult tracheal intubation. If the historical information from the anaesthesia record of this previous surgery clearly documented uncomplicated direct laryngoscopy for a recent surgery, the anaesthesia provider may then proceed with routine laryngoscopy. .
In conclusion, I think the presence of an completed anaesthetic record in a medical record documenting the anaesthesia used and anaesthetic technique, is sufficient evidence to justify full compliance with JCI Standard ASC.5.2
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
