TULANE UNIVERSITY HOSPITAL & CLINIC
Policies & Procedures Manual
Policy No: ANES 6.0a
Page: 1 of 1
Effective Date: February 13, 2006
Supersedes Policy:
Policy Origin Date:
Last Reviewed: September 8, 2014
Dated: November 1993
May 2000/May 17, 2005
Originating Dept./Committee: Anesthesiology April 2003
TITLE: DOCUMENTATION OF ANESTHESIA CARE (PRE & INTRAOPERATIVE)
PURPOSE: To provide a guidelines of documenting during procedures that require anesthesia.
POLICY: DOCUMENTATION OF ANESTHESIA CARE (PRE & INTRAOPERATIVE)
PROCEDURE:
The record should include documentation of:
I. Pre-Operative Evaluation
A. Patient interview to review
1. Medical history
2. Anesthesia history
3. Medication history
B. Appropriate physical examination
C. Review of objective diagnostic data (e.g., laboratory, ECG, X-ray)
D. Assignment of ASA physical status
E. Formulation and discussion of an anesthesia plan with the patient and/or responsible adult.
II. Intra-operative Evaluation (time-based record of events)
A. Immediate review prior to initiation of anesthetic procedures:
1. Patient reevaluation by the anesthesiologist including updated vitals and physical exam.
2. Check of equipment, drugs and gas supply
B. Procedure including side, site, location. The procedure should be updated at the conclusion of
procedure to reflect the actual procedure performed if consents were obtained for additional,
possible procedures.
C. Monitoring and recording of vitals signs including blood pressure, heart rate, respiratory rate,
pulse oximetry, rhythm, urine output, and invasive monitors as indicated.
D. Amounts of all drugs and agents used, and times given.
E. The type and amounts of all intravenous fluids used, including blood and blood products, and
times given.
TULANE UNIVERSITY HOSPITAL & CLINIC
Policies & Procedures Manual
Policy No: ANES 6.0a
Page: 2 of 1
Effective Date: February 13, 2006
Supersedes Policy:
Policy Origin Date:
Last Reviewed: September 8, 2014
Dated: November 1993
May 2000/May 17, 2005
Originating Dept./Committee: Anesthesiology April 2003
F. The technique(s) used.
G. The results of all intraoperative labs including blood gasses, glucose, thromboelastogram, and
any other lab tests as indicated.
TULANE UNIVERSITY HOSPITAL & CLINIC
Policies & Procedures Manual
Policy No: ANES 6.0a
Page: 3 of 1
Effective Date: February 13, 2006
Supersedes Policy:
Policy Origin Date:
Last Reviewed: September 8, 2014
Dated: November 1993
May 2000/May 17, 2005
Originating Dept./Committee: Anesthesiology April 2003
H. Unusual events during the anesthesia period. The narrative section of the record
should be reserved to convey details of pertinent intraoperative events.
I. The status of the patient at the conclusion of anesthesia.
J. Ventilator settings including mode, respiratory rate, tidal volume, and inspired
oxygen concentration.
K. Preoperative antibiotics including date, time and indication if not given.
L. Procedure note for all minor procedures including neuraxial blockade, peripheral
nerve blockade, invasive line placement, and intubation.
See Attachment A – Anesthesiology Record