Page 22 - 2022 Risk Basics - Anesthesiology

SVMIC Risk Basics: Anesthesiology

Other things to keep in mind with regard to the informed

consent discussion would be that the discussion should be in
terms understandable to a lay person. Also, you should

educate and get consent forms signed prior to the

administration of any sedation, and ensure the patient has time
to ask questions.

The medical record should include patient-specific notes and

references. In the case of patients who have consented to
regional anesthesia, the risks of an emergency dictating the

administration of general or additional anesthesia should be

explained to the patient and documented in the record as
there may not be time to obtain additional informed consent

from the patient.

Intraoperative

In addition to documentation problems with the pre-

anesthesia record, our claims review reveals a number of
inadequate documentation issues within the anesthesia

record. What was often missing in cases evaluated include:

 Details about emergency response and interventions

 Maneuvers utilized for managing a difficult airway,

positioning, and padding details

 Presence of eye protection

 Timeout

 Presence of anesthesiologist during induction and
emergence

 Interventions taken

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