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Blood pressure is displayed in the upper right corner of the monitor in pink/purple. The systolic (top number) represents pressure in the blood vessels while the heart contracts. The bottom number is the diastolic blood pressure, the pressure exerted on the blood vessel walls when the heart relaxes.
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.
A capnograph is especially useful in determining the patients respiratory rate when chest movement or movement of the anesthetic bag is difficult to see. Capnography readings can also provide the first signs of problems in the anesthetic breathing circuit.
The anesthesia record is a document that provides information about perioperative care. This provides data on preoperative assessment, anesthesia management, vital parameters, and intraoperative events.
Patient assessment data: Patient and procedure identification; Anticipated disposition; Medical history includes patients ability to give informed consent; Surgical and Anesthetic history; Current Medication List (pre- and post-admission); Allergies/Adverse Drug Reaction (including reaction type); NPO status;
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Therefore, the development of an anesthesia plan starts with a pre-anesthetic patient assessment. Pre-anesthetic patient assessment. Anticipated anesthesia and procedural problems. Anesthesia drug and support therapy. Physiological monitoring. Post anesthesia recovery. Collaboration and plan authorization.
The proper way to report anesthesia time is to record it in minutes. One unit of time is recorded for each 15-minute increment of anesthesia time. For example, a 45-minute procedure, from start to finish, would incur three units of anesthesia time. Being exact is required, since Medicare pays to one-tenth of a unit.
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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