What do you guys write on the anesthesia record if anything?

[RussianJoo]

Just wondering what you guys write in the comments section of the anesthesia record. I remember there was a standard thing that the residents at a program I rotated as a med student wrote for every case , something like "pt moved to the OR table, Standard ASA monitors applied..."

My program doesn't have any guidelines on what to write. We have spaces for start time, incision, end time, I usually write end of surgery time and out of the OR time, then I'll write if the surgeon used any local how much and what kind, if something bad happened or unexpected event, if we're on hold for the PACU, if the labs are abnormal but the surgeon wants to proceed. extubation criteria for difficult intubations and morbidly obese. Tourniquet up and down times, and sometimes important or relevant pre-op labs. But a lot of times I end up writing only the surgery End time and Out time.

I've seen people write +ve or -ve PONV...

What are somethings you guys write on your forms?

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[btbam]

I'm not big on extraneous info on the chart,
But I'll write an extubation note saying it went smooth, pt suctioned VSS etc..transported to PACU on O2

 

[Unknown3234]

my attending usually writes something along the lines of:
to OR #2, monitors on, preoxygenated, smooth intubation
pt suctioned, spontaneous breaths, extubated, VSS, to pacu

 

[pgg]

If there's a box to X, I generally don't write it again. That usually doesn't leave much to write.

Narratives for lines, non-ASA monitors, regional, OG/NG tube placement, not much else. Maybe a comment re: ease or difficulty of mask ventilation if the airway is not trivial.

A short comment about LOC at extubation.

 

[epidural man]

Just wondering what you guys write in the comments section of the anesthesia record. I remember there was a standard thing that the residents at a program I rotated as a med student wrote for every case , something like "pt moved to the OR table, Standard ASA monitors applied..."

My program doesn't have any guidelines on what to write. We have spaces for start time, incision, end time, I usually write end of surgery time and out of the OR time, then I'll write if the surgeon used any local how much and what kind, if something bad happened or unexpected event, if we're on hold for the PACU, if the labs are abnormal but the surgeon wants to proceed. extubation criteria for difficult intubations and morbidly obese. Tourniquet up and down times, and sometimes important or relevant pre-op labs. But a lot of times I end up writing only the surgery End time and Out time.

I've seen people write +ve or -ve PONV...

What are somethings you guys write on your forms?

I used to right a small narrative - now we have computers doing all the charting. I love it - and I don't type a note that would have been similar to what I wrote on the paper chart.

Computer charting is great for the case - but they suck to review.

The other day I forgot to chart the morphine on my first case - and realized this at the end of the day. It was so easy to open the chart - add it, reprint for the narc police. It would have been a huge pain using the paper charting.

 

[RussianJoo]

if there's a box to x, i generally don't write it again. That usually doesn't leave much to write.

Narratives for lines, non-asa monitors, regional, og/ng tube placement, not much else. Maybe a comment re: Ease or difficulty of mask ventilation if the airway is not trivial.

A short comment about loc at extubation.

loc?

 

[RussianJoo]

I used to right a small narrative - now we have computers doing all the charting. I love it - and I don't type a note that would have been similar to what I wrote on the paper chart.

Computer charting is great for the case - but they suck to review.

The other day I forgot to chart the morphine on my first case - and realized this at the end of the day. It was so easy to open the chart - add it, reprint for the narc police. It would have been a huge pain using the paper charting.

if you don't mind, could you post what you used to write when you used paper anesthesia records?

Thanks,

 

[RussianJoo]

So I guess the consensus is that there's no need to write much at all? Sounds good to me, I just wanted to make sure I wasn't missing anything.

 

[btbam]

loc?

level of consciousness

 

[loveumms]

I guess I'm an over-writer.

I would write something like: pt seen, eval, consent +. To OR #2, onto OR table, SASAM +/- whatever else (a-line inserted under sterile conditions using seldinger tech: central line inserted with ultrasound guidance, easily threaded using seldinger tech; ect). pre O2 via mask, IV induction, eyes taped, easy mask, DL x1 with MAC 4, G I view: 8.0 ETT through VC, cuff to seal: +ETCO2, L=R. ETT secured. PP checked, adequate padding at all PP, arms abducted <90 degrees and supinated, knees on cushion: head on pillow.

THen I would write time I turned over to surgeon and surgical start time. Any local that was given. I always write down any discussions I have with the surgeon and the outcome.

I always thought the more I wrote the better. Really, the record is the only thing you have proving what you did for the patient. I want to be able to go back and know what I did or didn't do (b/c years after the case, you probably won't remember what happened).

 

[periopdoc]

My typical notes for a cardiac case. Mostly this provides prompts for me to remember how the case went down (should I ever be asked), and provide necessary documentation for billing compliance. I do not chart things that are implicit in my other documentation. IE it is not possible for me to have data from all ASA monitors if they were not applied. Since I chart all the data I do not write a statement that I applied monitors (that is redundant IMHO) I know that others disagree with this sentiment and you should probably listen to them. This is how I do it though.


Met in preop holding (or OR or ED or wherever)
Reviewed Hx/Plan/Risks

R radial A-line in USF. Cap/ soap and water/ gloves/ chlorhex. 20 g Arrow. Bio-occlusive dressing applied.

To OR

Smooth IVI/ Easy Mask/Atraumatic DL/ Eyes taped/ Arms tucked

TEE probe placed easily and atraumatically

U/S guided RIJ PAC in USF. Cap/mask/gel/gown/gloves. Chlorhex/ full body drape/ US condom. RIJ identified in SAX, widely patent and adjacent to carotid art. Needle passed into RIJ vein with real-time visualization. Wire confirmed in RIJ vein in SAX and LAX, image in chart. Catheter hubbed, sutured. PAC introduced sterilely into swandom then introducer. Floated into PA with waveform and TEE guidance. Bio-occlusive dressing applied.

PPP/PPV (pressure points padded/ pre-procedure verification)

Record intraoperative events as necessary

Awakened, extubated, to PACU stable. or Transported to ICU stable, report given. (Since I am documenting BP, pulse, resp, SaO2 during transport, I do not bother to write that I used monitoring during transport.)

ANYTHING that varies from the norm or routine I will document extensively. Otherwise, I try to be brief and to the point.

Like I said, others will disagree with my method, and they may be right. I believe I have enough info to defend myself if necessary without too much info that would paint me into a corner.

Hope that helps.


- pod

 

[RussianJoo]

I guess I'm an over-writer.

I would write something like: pt seen, eval, consent +. To OR #2, onto OR table, SASAM +/- whatever else (a-line inserted under sterile conditions using seldinger tech: central line inserted with ultrasound guidance, easily threaded using seldinger tech; ect). pre O2 via mask, IV induction, eyes taped, easy mask, DL x1 with MAC 4, G I view: 8.0 ETT through VC, cuff to seal: +ETCO2, L=R. ETT secured. PP checked, adequate padding at all PP, arms abducted <90 degrees and supinated, knees on cushion: head on pillow.

THen I would write time I turned over to surgeon and surgical start time. Any local that was given. I always write down any discussions I have with the surgeon and the outcome.

I always thought the more I wrote the better. Really, the record is the only thing you have proving what you did for the patient. I want to be able to go back and know what I did or didn't do (b/c years after the case, you probably won't remember what happened).

why do you supinate the arms?

And you mean discussions about the pt right? For example we had a conversation in the OR yesterday about what actresses we thought were hot, and the outcome was that the surgeon likes Sandra Bullock. You wouldn't document that would you?

 

[RussianJoo]

My typical notes for a cardiac case. Mostly this provides prompts for me to remember how the case went down (should I ever be asked), and provide necessary documentation for billing compliance. I do not chart things that are implicit in my other documentation. IE it is not possible for me to have data from all ASA monitors if they were not applied. Since I chart all the data I do not write a statement that I applied monitors (that is redundant IMHO) I know that others disagree with this sentiment and you should probably listen to them. This is how I do it though.


Met in preop holding (or OR or ED or wherever)
Reviewed Hx/Plan/Risks

R radial A-line in USF. Cap/ soap and water/ gloves/ chlorhex. 20 g Arrow. Bio-occlusive dressing applied.

To OR

Smooth IVI/ Easy Mask/Atraumatic DL/ Eyes taped/ Arms tucked

TEE probe placed easily and atraumatically

U/S guided RIJ PAC in USF. Cap/mask/gel/gown/gloves. Chlorhex/ full body drape/ US condom. RIJ identified in SAX, widely patent and adjacent to carotid art. Needle passed into RIJ vein with real-time visualization. Wire confirmed in RIJ vein in SAX and LAX, image in chart. Catheter hubbed, sutured. PAC introduced sterilely into swandom then introducer. Floated into PA with waveform and TEE guidance. Bio-occlusive dressing applied.

PPP/PPV (pressure points padded/ pre-procedure verification)

Record intraoperative events as necessary

Awakened, extubated, to PACU stable. or Transported to ICU stable, report given. (Since I am documenting BP, pulse, resp, SaO2 during transport, I do not bother to write that I used monitoring during transport.)

ANYTHING that varies from the norm or routine I will document extensively. Otherwise, I try to be brief and to the point.

Like I said, others will disagree with my method, and they may be right. I believe I have enough info to defend myself if necessary without too much info that would paint me into a corner.

Hope that helps.


- pod

Thanks, you write all this on the anesthesia record or do you use a blank progress note page and just leave it as that in the chart?

I definitely document in great detail when ever something goes wrong, but if everything was fine then I don't write anything down.

 

[RussianJoo]

level of consciousness

is there a classification system that you use? or do you just say "awake, alert, following commands, drowsy, sedated, unconscious, dead" ?

 

[Sergio99]

We have checkboxes for almost everything, but I write a few things just to show the order in which I did them, mainly to show that the eyes were taped immediately after induction, before any manipulation of the airway or anyting else on the face. Once somebody accuses you of not taping the eyes, you become paranoid and want them to know not only that you did it, but also when you did it.

And if there is anything unusual, I document it as well, but for the routine cases, we have checkboxes for everything, so that you could do a case almost without having to write anything. We even have some checkboxes for our quality control people to know whether we complied with SCIP measures or not without having to look for them in the record.

 

[btbam]

is there a classification system that you use? or do you just say "awake, alert, following commands, drowsy, sedated, unconscious, dead" ?

we have an electronic system for PACU stuff, which includes LOC, is the pt stable etc...
So the only note I write on the record (assuming everything goes fine) is something like: patient suctioned/extubated in OR without problem, responsive to commands,VSS, transported to PACU with O2 via facemask at 6L/min.

 

[jwk]

I guess I'm an over-writer.

I would write something like: pt seen, eval, consent +. To OR #2, onto OR table, SASAM +/- whatever else (a-line inserted under sterile conditions using seldinger tech: central line inserted with ultrasound guidance, easily threaded using seldinger tech; ect). pre O2 via mask, IV induction, eyes taped, easy mask, DL x1 with MAC 4, G I view: 8.0 ETT through VC, cuff to seal: +ETCO2, L=R. ETT secured. PP checked, adequate padding at all PP, arms abducted <90 degrees and supinated, knees on cushion: head on pillow.

THen I would write time I turned over to surgeon and surgical start time. Any local that was given. I always write down any discussions I have with the surgeon and the outcome.

I always thought the more I wrote the better. Really, the record is the only thing you have proving what you did for the patient. I want to be able to go back and know what I did or didn't do (b/c years after the case, you probably won't remember what happened).

Yours is a great example of how checkboxes can make your life so much easier (do you really WRITE all this stuff???). These are just my opinion:

Every item in your first paragraph can be done with a checkbox, or maybe some of it not done at all.

Pt seen, eval, consent, etc. - all covered in your pre-anesthesia evaluation prior to surgery. No reason to repeat it on your record.

To OR #2, onto OR table, SASAM +/- - why is this necessary? Your record probably has a spot on it for the OR#. Having the pt on the OR table is a given. You're recording all your monitored values - no need to write that you applied monitors.

Almost anything dealing with intubation notes and position can be done with a checkbox.

Any invasive line or block that we place pre- or intra-op has a separate pre-printed note with lots of checkboxes. They take all of 20 seconds each to complete if needed.

Your idea of documenting surgical discussions is interesting, but I can't imagine I would need to do that with any frequency. I DO document things like "surgeon states he has a vascular injury" or "surgeon says he punctured the diaphragm, and to please watch for a pneumo".

I rarely if ever write down something I didn't do personally. Local by surgeon? Not really an anesthesia concern although I do stay aware during gigantic liposuction. Tourniquet times? I don't apply tourniquets, I don't inflate or deflate them - is there a reason for me to document it? Not in my book. It's a surgical aid, not an anesthetic device. The nurses put it on their OR record.

If your records are like mine (and most I've seen are) there's very limited space for written comments. If you've run out of writing space and haven't made the incision (I have students do this all the time), what are you going to do?

All that being said, I WILL document anything out of the ordinary (surgeon inadvertently injects local into carotid). I just don't see the point of documenting "normal" findings in written form.

I also document delays - I think it's important to note things like "0745 - pt prepped and draped and awaiting surgeon" when the incision time is 0815, or "1030 - delay for PACU bed - pt awake and responsive" when the anesthesia end time is 1115.

I can (and have had to) go back years later and see exactly what I did during a case, even with minimal handwritten comments. I don't have to guess what I did.

One last comment - make sure your records are legible if you still have to write them by hand.

 

[Impromptu]

My residency has a computerized chart. Fantastic invention.

I'm currently at a private practice hospital doing a rotation. When I review the prior anesthesia records that are scanned into EPIC (cheers or hisses), I cannot read what the CRNAs or AAs have written. Completely illegible. As are the notes that the attendings scribbe onto the charts. I can read the checkboxes.

I write legibly. Looking at these other records I can see a malpractice lawyer jumping for glee.

 

[TrustMe]

Smooth/unevetful induction.
Stable throughout case.
Extubated. To PACU. Stable.

 

[joshmir]

can you bill for controlled hypotension if you document it?

I have heard an anesthesiologist got dropped out of a lawsuit b/c he wrote "atraumatic OGT insertion" so I will write that

i write arms supinated, and for prone cases i document eyes and ears periodically evaluated and continued to remain free of pressure"

for regional

for LE blocks I document there is a plan for fall precautions and if its the primary team that will be in charge of the fall precaution plan (ie, knee imobilizers, etc)

for all blocks the onset of motor block is a bit delayed usually and I will write that because if you inject intraneural you can get an immediate motor block

i document lack of paresthesia, and lack of resistance to injection of local (ie low pressure injection)

 

[Consigliere]

I sign my name and that's all.