Importance of Clinical Documentation in Anesthesia Care

Doctors reading information on computer

Clinical documentation in anesthesia care is an essential element of safe, high-quality medical care. Anesthesia providers must value the importance of accurate and thorough documentation and diligently record it. Whether captured digitally or traditionally, documentation is a significant part of an anesthesiologist’s or CRNA’s role and should be taken seriously. Improving clinical documentation in anesthesia care should always be a priority, no matter how accurate and thorough it may currently be. 

How to Use Anesthesia’s Clinical Documentation 

Documentation is completed in all three phases of anesthesia-related care: pre-anesthesia, intraoperative anesthesia, and post-anesthesia. While this documentation is completed in accordance with The Joint Commission, Centers for Medicare and Medicaid Services, and DNV GL compliance standards, it is also important in informing progress toward reversing inefficiencies. For example, CCI Anesthesia routinely reviews OR utilization reports and First Case On-Time Start rates to guide our efforts on adjustments that can be made to support efficiency. We also strive to implement Enhanced Recovery After Surgery (ERAS) protocols that can lead to shorter PACU times and reduced in-patient stays. 

To better understand how anesthesia’s clinical documentation can support your facility’s efficiency goals, examine the data points captured by anesthesia providers:

Pre-anesthesia Evaluation

The pre-anesthesia evaluation is collected via a patient interview. In addition to typical medical history questions and NPO status, anesthesia providers will:

  • Conduct an appropriate physical examination including vital signs, height, weight, and documentation of airway assessment and cardiopulmonary exam.
  • Review objective diagnostic data and medical records.
  • Assign an ASA physical status.
  • Document the anesthetic plan, including post-anesthesia and pain management care plans.
  • Document informed consent of the anesthetic plan and post-operative pain management plan.
  • Administer appropriate premedication and prophylactic antibiotics.

Intraoperative/Procedural Anesthesia Documentation

The intraoperative documentation aspect of anesthesia care is a time-based record of events in the operating room. This information is beneficial when looking for ways to reverse operating room inefficiencies. In addition to physiologic monitoring data, intraoperative charting captures:

  • Medications administered 
  • Intravenous fluids delivered
  • Anesthesia techniques used
  • Patient positioning and actions to reduce the chance of adverse patient effects or complications
  • Additional procedures performed (for example, use of ultrasound)
  • Unusual or noteworthy events during surgery
  • Patient status at the transfer of care to the PACU.

Post-anesthesia Documentation

Post-anesthesia documentation is a time-based record of events reflecting the patient status on admission and discharge from the PACU as determined by a qualified anesthesia provider. This record would include any significant or unexpected post-procedural events or complications. It would also document the patient’s physiologic condition and the presence or absence of any anesthesia-related complications or complaints. 

Transforming Anesthesia Documentation into Data 

Analyzing detailed clinical information such as drugs and agents utilized, order sets and equipment used can be incredibly valuable in eliminating wastage, increasing operating room turnover and enhancing other efficiencies. Clinical indicators and complication information collected for every patient is also helpful in predicting surgical case duration. Keep in mind that collecting this data is one thing; interpreting it is another. Implementing an anesthesia informatics management system (AIMS) makes analyzing anesthesia data accessible and allows other departments to make more informed decisions.  

Implementing AIMS at Your Facility 

We have helped many clients choose and implement the right AIMS for their unique needs. We can also advise on avoiding common pitfalls when implementing AIMS and customizing the EMR to your facility. Since AIMS improves many of the shortcomings of manual data collection, it can be paramount to converting data into valuable knowledge.

For more information on improving anesthesia clinical documentation, call our anesthesia practice management experts at 800.494.3948 to learn more.