Page 17 - 2022 Risk Basics - Anesthesiology

SVMIC Risk Basics: Anesthesiology

that “my surgeon was in a hurry to start the procedure” will not

be well-received by a jury.

A similar caution applies to outside consultations and surgical
clearances. The anesthesiologist should either review a copy of

the dictated consult or speak to the physician involved. There
may be medical information in the consult that is not available

elsewhere in the chart. The consultant may have had access to

old records or to history from the patient’s relatives that is not
available to you. These efforts need to be documented.

Some consultants may suggest specific monitoring. You

should address such issues before starting the procedure. If
you do not agree with the suggestion, it is best to discuss it

with the consulting physician and document the discussion.

This helps avoid the appearance that you are acting against
another physician’s advice.

Hospitals and practices should develop policies and

procedures which address how information should be
consistently documented regarding patient evaluations. These

policies and procedures should be structured so as to prevent
duplicative information contained elsewhere in the medical

record. Every member of the anesthesia care team should be

familiar with the policies and procedures regarding the method
of documentation.

The ASA has provided an outline of the documentation needed

in the pre-anesthesia evaluation:

 Patient and procedure identification

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