Medical record anesthesia 2025

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Your anesthesia risk might be higher if you have or have ever had any of the following conditions: Allergies to anesthesia or a history of adverse reactions to anesthesia. Diabetes. Heart disease (angina, valve disease, heart failure, or a previous heart attack)
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;
An anesthesia record should be devised for record keeping and to track the number of procedures and complications. Ideally, the anesthesia record should remain in the patients permanent medical record and a copy kept for quality assurance and improvement.
I. Preanesthesia Evaluation* Patient and procedure identification. Anticipated disposition. Medical history includes patients ability to give informed consent. Surgical History (PSHx) Anesthetic history. Current Medication List (preadmission and postadmission) Allergies/Adverse Drug Reaction (including reaction type)
The anesthetic record helps to document all the important perioperative data. Documented records can serve as legal documents during the legal liability of anesthesia professionals. It is also used to maintain a safe practice of anesthesia and for research purposes [5].
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General Anesthesia Record Several vital functions (e.g., heart rate and rhythm, respiration, SpO2, temperature, and ETCO2) are monitored continuously, whereas others, including blood pressure, are monitored at intervals of 5 minutes.

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