Page 16 - 2022 Risk Basics - Anesthesiology

SVMIC Risk Basics: Anesthesiology

a thorough interview of the patient and/or family members

should be conducted, inquiring as to the patient’s history of
airway difficulty, snoring, apneic episodes, etc. The responses

to the interview need to be noted. A physical exam using a

classification system such as Mallampati helps demonstrate
that a thorough airway exam was performed. The Mallampati

score needs to be documented along with any other pertinent
information relating to the airway and/or OSA. If a patient has

or is suspected to have OSA, the anesthesiologist should

coordinate with the surgeon to develop a protocol for a
perioperative management plan. The written anesthesia plan

should reflect this protocol.
5

Documentation includes not only writing/typing notes in the
record but also reviewing pertinent documentation available to

the anesthesia practitioner before beginning a procedure. This
includes, but is not limited to, sleep studies, labs, medication

allergies, cardiac testing, etc. In the rush to start a procedure,

for example, the anesthesiologist may not wait for lab values to
return. Pending laboratory tests should not be ignored. For

non-emergencies, all preoperative labs that could potentially

change your course of action should be available and read. As
discussed elsewhere, the EHR’s audit trail will reveal whether

or not existing records were accessed. Remember that all lab
and diagnostic results will be in the patient’s chart when it is

reviewed in a subsequent malpractice case. Retrospectively,
you may appear negligent if you have not reviewed all of the

information that was potentially available to you. The argument

5 http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1917935

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