Recording anesthesia info in medical records

Article

When you administer anesthesia, make sure you completely document the process.

Anesthesia information is a critical component of medical records. Properly recording it protects the practice if something goes wrong during surgery, and it protects pets that undergo additional surgeries in the future.

What anesthesia information to record:

Results of the physical examination given prior to administering anesthetic; methods and levels of anesthesia (general or local), analgesia and sedation used; all drugs and equipment used to treat medical emergencies if they arose during surgery; use of an supplemental heat for intra-op, post-op and critical care patients; issues or problems with anesthesia during surgery; recovery information

Who should record it:

The technician is responsible for recording all details surrounding anesthesia, including preoperative, surgery, and postoperative information.

When anesthesia information should be recorded:

Make notations before, during, and after the procedure so the record is always up to date.

Why this is important: 

While anesthesia is safe, many clients fear it. In the unlikely event of a complication, thorough documentation ensures you can illustrate that you properly administered the anesthetic. Also, if a pet reacts badly to a particular anesthesia, noting this in the record allows future veterinarians to avoid using it.

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Angela Elia, BS, LVT, CVT, VTS (ECC)
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