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What documentation is necessary for anesthesia?

Appropriate physical examination, including vital signs, height and weight and documentation of airway assessment and cardiopulmonary exam. Review of objective diagnostic data (e.g., laboratory, ECG, X-ray) and medical records. Medical consultations when applicable.

What are the responsibilities of an anesthesiologist?

Physician anesthesiologists evaluate, monitor, and supervise patient care before, during, and after surgery, delivering anesthesia, leading the Anesthesia Care Team, and ensuring optimal patient safety. Physician anesthesiologists specialize in anesthesia care, pain management, and critical care medicine.

How is anesthesia reported?

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.

What is an anesthesia report?

Anesthesia documentation represents a detailed account of the patient's anesthesia care during various phases of anesthesia, including preanesthesia assessment and evaluation, informed consent, anesthesia services, and postanesthesia care.

What is the importance of patient assessment prior to administration of local anesthetics?

This kind of information deficit has the potential to cause major problems when it comes to anesthesia, so it's essential to conduct a physical assessment in order to evaluate the patient's vital signs. These vital signs can identify conditions that may require a change in treatment.

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