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LNCtips.com: Anesthesia Record Analysis

When I was a new legal nurse consultant, analysis of hand-written anesthesia records drove me crazy. All that data crammed onto one page was overwhelming. However, I found ways to simplify the interpretation of all that information. And talk about simple - I use a trio of low-tech tools to help me out.

Before I discuss the tools, let's talk about overwhelming tasks. The cure for being overwhelmed is to break down big endeavors into manageable pieces.  With that in mind before I begin my review, I mentally divide the anesthesia record into sections.  For example, there are sections for the monitors and equipment used during anesthesia administration, types of airway used, the anesthetic agents, and vital signs.

The three tools that I use are a marker, a magnifier, and a guide. I print or copy the anesthesia record so that I can alter the copy without affecting the original. Then, I review each of the sections one-by-one to create a minute-by-minute medical chronology. If you have a good eye, you can use the magnifier and highlighter with electronic records instead of printing the anesthesia record.

Anesthesia records contain a graph with boxes for the patient's vital signs and other information. Each box denotes a five-minute increment. On some forms, the boxes are only one-eighth inch wide. For those records, I use a guide (a ruler or even the edge of a piece of paper) to line up the information within each five minute increment. As I review, I use a yellow highlighter to mark every piece of information after I've entered it into the chronology. That way, I don't miss information or enter it more than once. I enlarge areas that are difficult to see by using a magnifying glass.

In addition to the anesthesia record, it's essential to review pre-anesthesia records, anesthesia orders, perioperative records and records related to post anesthesia recovery. Note crucial times, including the time of patient transport to the room, the starting time for anesthesia personnel, the induction time, the start time of surgery, the end time of surgery, and the end time of anesthesia. If the times aren't in the anesthesia records, you'll find them in the operating room and/or recovery room records. Determine if the time of the incident correlated to the induction time or start of surgery.

As you review the records, ask yourself some questions. Did an anesthesiologist or CRNA perform a pre-anesthesia assessment? If it was a CRNA, did an anesthesiologist review the assessment and co-sign it? When did the pre-anesthesia assessment occur? If it was several days prior to surgery, was there another anesthesia assessment the day of surgery to confirm the original findings? Did the pre-anesthesia assessment include review of the history and physical, pertinent laboratory results and EKG if warranted? Did anesthesia personnel note significant findings? Did the patient sign a consent form that outlined the risks and benefits of anesthesia?

Did anesthesia personnel note the patient's dentition (e.g., dentures, loose teeth)? What were the patient's ASA class and Mallampati score? The Mallampati score refers to the predicted ease of intubation. It's graded from Class 1 (easiest to intubate) to Class 4 (most difficult to intubate). ASA scores range from ASA 1 (healthy) to ASA 6 (brain dead). What type of anesthesia (general, spinal, regional, monitored anesthesia care) did anesthesia personnel use?

Who administered the anesthesia? If it was a CRNA, was there a supervising anesthesiologist? Was the anesthesiologist present during induction and/or emergence from anesthetic care? Did anesthesia personnel administer appropriate medications in response to changes in vital signs? Had the patient recovered sufficiently before transfer to the recovery room or ICU?

Who administered the anesthesia? If it was a CRNA, was there a supervising anesthesiologist? Was the anesthesiologist present during induction and/or emergence from anesthetic care? Did anesthesia personnel administer appropriate medications in response to changes in vital signs? Had the patient recovered sufficiently before transfer to the recovery room or ICU?

If you are reviewing electronic anesthesia records, make sure that you have a copy of the electronic anesthesia graph.  It may not be provided unless specifically requested.  Without the graph, you may not have access to the entire anesthesia records.

Analysis of anesthesia records may be challenging, but it doesn't have to be overwhelming.

Want to learn about LNC skills?  Check out the Archives.

...Katy Jones