Page 15 - Part 1 Anesthesiology Common Risk Issues

SVMIC Anesthesiology: Common Risk Issues

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.

Your medical history and exam should pay special attention

to pre-op tests ordered and the results. There should be a
tracking system to ensure pre-op tests ordered are recognized

and reviewed as they may have implications on whether a
medical clearance consult is needed or whether a change in

the anesthesia plan is prudent. Look for and document any
significant comorbidities or history that can increase the risk

of difficult intubation or emergence such as Obstructive Sleep
Apnea, chronic narcotic use, etc. Be aware of the ASA difficult

airway algorithm, and in your evaluation of the airway, include
the classification. Careful triage based on a patient’s history can

help avoid unnecessary assessment of low-risk patients and
ensure that necessary assessments for higher-risk patients are

completed before the day of surgery.

Document the details of the dental examination, and note if

everything is intact. If there are loose teeth or caps, note such
by location. Dental claims (which will be discussed in a separate

topic later in this course) are not high dollar, but they are more
frequent and can cause significant defense expense. Often,

anesthesia groups elect to pay the expenses related to dental

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