The anesthesia record.
The standard format of preoperative, perioperative, and postoperative patient anesthesia records, the categories of information included, and pharmacists use of this information are described. On the preoperative evaluation form, the anesthesiologist or anesthetist records information on the physical status of the patient and an overall impression of the anesthetic risk. The perioperative record is used for notation of the administration of anesthetic agents, fluids, blood products, and other medications and for recording vital signs, anesthetic and surgical interventions, and airway maintenance; this record shows a dynamic account of the patient's responses throughout the operation. Finally, the anesthesiologist notes postoperative problems related to anesthesia on the postoperative section of the record. The anesthesia record can be used by pharmacists for medication scheduling and therapeutic drug monitoring, assessment of fluid status, evaluation of hemodynamic response to drug and fluid interventions, quality assurance, and drug-use reviews.
Department of Pharmacy, Robert Wood Johnson University Hospital, New Brunswick, NJ 08901.
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Penn
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Coplin
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Kirzecky
D000776:Anesthesiology; D005568:Forms and Records Control; D006801:Humans; D008499:Medical Records; D009515:New Jersey; D010348:Patient Care Team; D010607:Pharmacy Service, Hospital; D011184:Postoperative Period; D011300:Preoperative Care