Evaluating the Patient Before Anesthesia - Documentation

The preoperative anesthesia note is a medicolegal document in the permanent hospital record. As such, it should be a concise, legible statement, which includes the date and time of the interview, the planned procedure, and laterality (if applicable). It should include relevant positive and negative findings from the history, physical examination, and laboratory studies including a list of allergies and relevant medications as discussed above. A problem list that delineates all disease processes, their treatments, and current functional limitations must also be included. The note should also detail the discussion that occurred with the patient including anesthetic options, particular risks, monitoring needs, and postoperative plans.

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