Page 19 - Part 1 Anesthesiology Common Risk Issues

SVMIC Anesthesiology: Common Risk Issues

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

• Anticipated disposition

• Medical history – includes patient’s ability to give informed

consent

• Surgical history

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