Page 12 - 2022 Risk Basics - Anesthesiology

SVMIC Risk Basics: Anesthesiology

key reason for indefensibility. Other documentation-related

issues were illegible documentation, erroneous entries, late or
untimely notations, apparent alterations of the chart, and EHR

issues.

The American Society of Anesthesiologists has divided each
anesthetic procedure into three primary stages or categories:

 Pre-anesthesia

 Intraoperative/intraprocedural anesthesia

 Post-anesthesia care

The anesthesiologist/CRNA should accurately document each

of these stages/categories of an anesthetic procedure. From a
risk standpoint, claims and lawsuits can arise during each of

these three phases; therefore, careful attention must be given
to fully documenting each appropriately. Regardless of

whether you are using paper or electronic records, accuracy

and timeliness are of paramount importance.

Pre-Anesthesia

In our claims review, we often find one or more of the crucial

pre-anesthesia documentation elements missing from the
record, which suggests they were not evaluated.

Documentation omissions include the classification of airway,

evaluation of neck extension, whether the history of prior
intubation difficulty was known or explored, whether there was

an evaluation for the presence or absence of obstructive sleep
apnea, and the lack of a dental assessment.

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