Evaluating the Patient Before Anesthesia - Documentation
is a topic covered in the Clinical Anesthesia Procedures
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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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Pino, Richard M., editor. "Evaluating the Patient Before Anesthesia - Documentation." Clinical Anesthesia Procedures, 9th ed., Wolters Kluwer, 2019. Anesthesia Central, anesth.unboundmedicine.com/anesthesia/view/ClinicalAnesthesiaProcedures/728519/all/Evaluating_the_Patient_Before_Anesthesia___Documentation.
Evaluating the Patient Before Anesthesia - Documentation. In: Pino RM, ed. Clinical Anesthesia Procedures. 9th ed. Wolters Kluwer; 2019. https://anesth.unboundmedicine.com/anesthesia/view/ClinicalAnesthesiaProcedures/728519/all/Evaluating_the_Patient_Before_Anesthesia___Documentation. Accessed October 18, 2019.
Evaluating the Patient Before Anesthesia - Documentation. (2019). In Pino, R. M. (Ed.), Clinical Anesthesia Procedures. Available from https://anesth.unboundmedicine.com/anesthesia/view/ClinicalAnesthesiaProcedures/728519/all/Evaluating_the_Patient_Before_Anesthesia___Documentation
Evaluating the Patient Before Anesthesia - Documentation [Internet]. In: Pino RM, editors. Clinical Anesthesia Procedures. Wolters Kluwer; 2019. [cited 2019 October 18]. Available from: https://anesth.unboundmedicine.com/anesthesia/view/ClinicalAnesthesiaProcedures/728519/all/Evaluating_the_Patient_Before_Anesthesia___Documentation.
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