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Who documents the anesthesia record?

On the preoperative evaluation form, the anesthesiologist or anesthetist records information on the physical status of the patient and an overall impression of the anesthetic risk.

What is the record for anesthesia?

The anesthetic record is the contemporaneous cataloguing of the events of the care of the patient. It is the permanent recording of these events. It serves as a lasting story of the anesthetic and how care elicited physiologic responses from a particular patient.

Who is responsible for anesthesia?

What is an anesthesiologist? Anesthesiologists are medical doctors just like your primary care physician and surgeon. They specialize in anesthesia care, pain management, and critical care medicine, and have the necessary knowledge to understand and treat the entire human body.

What are the contents of the anesthesia record?

The anesthesia record provides information about detailed perioperative care, which includes preoperative assessment, anesthesia management, vital parameters, and intraoperative events. Accurate and complete anesthesia documentation is a must for the following reasons: to enable preanesthetic planning.

How do you write an anesthesia record?

How Complete Is Your Anesthesia Record? Medical billing is all about appropriate documentation. Staffing Information and Start/Stop Times. Final Surgical Procedure(s) Performed. Final Diagnosis. Final Mode of Anesthesia. ASA Physical Status. Qualifying Circumstances Emergency and Deliberate Hypotension. Acute Pain Blocks.

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