What kind of pre-procedure assessments are appropriate to undertake before performing a procedure on a patient in an OHP?

The Procedures Standard requires that an appropriate pre-procedure assessment is undertaken by the physician performing the procedure including a baseline history and physical examination.

Where anesthesia or sedation will be administered, the Standard also requires the physician administering the anesthesia or sedation to complete a pre-anesthetic assessment. Such an assessment would typically include the following:

• American Society of Anesthesiologists’ (ASA) physical status classification of the patient
• a review of the patient’s clinical record (including pre-procedure assessment)
• an interview with the patient
• a physical examination relevant to anesthetic aspects of care
• a review and ordering of tests as indicated
• a review or request for medical consultations as necessary for patient assessment and planning of care
• a review of pre-procedure preparation such as fasting, medication, or other instructions that were given to the patient.

When determining which tests are indicated or appropriate for a particular patient, physicians may wish to consult Choosing Wisely Canada’s recommendations in relation to anesthesia.

What elements of patient care need to be documented when administering anesthesia or sedation in an OHP?

When anesthesia or sedation is administered, an Anesthesia/Sedation Record is required to be completed. A typical Anesthesia/Sedation record includes the following information:

1. pre-procedure anesthetic/sedation assessment
2. all drugs administered including dose, time, and route of administration
3. type and volume of fluids administered, and time of administration
4. fluids lost (e.g., blood, urine) where it can be measured or estimated
5. measurements made by the required monitors:
   • Oxygen saturation must be continuously monitored and documented at frequent intervals (at least every 5 minutes). In addition, if the trachea is intubated, a supraglottic airway is used, or moderate to deep sedation is being administered, end-tidal carbon dioxide concentration must be continuously monitored and documented at frequent intervals
   • Pulse and blood pressure documented at least every 5 minutes until patient is recovered from sedation
   • Temperature and neuromuscular blockade monitors
6. complications and incidents (if applicable)
7. name of the physician responsible (and the name of the person monitoring the patient, if applicable)
8. start and stop time for anesthesia/sedation care.¹

What elements of care need to be documented during the recovery period?

In relation to care provided during the recovery period appropriate documentation would typically include:

1. patient identification
2. date and time of transfer to recovery area
3. initial and routine monitoring of: blood pressure, pulse, respirations, oxygen saturation, temperature, level of consciousness, pain score, procedure site and general status
4. continuous monitoring of vital signs until the patient has met requirements of discharge criteria using an objective scoring system from time of transfer to recovery area until discharge
5. medication administered: time, dose, route, reason, and effect
6. treatments given and effects of such treatment
7. status of drains, dressings, and catheters including amount and description of drainage
8. summary of fluid balance
9. discharge score using a validated discharge scoring system.

What other documents or notes would typically be included in the patient record?

CPSO’s Medical Records Documentation policy states that the goal of the medical record is to “tell the story” of the patient’s health care journey. In order to ensure that a full picture of the patient’s health care journey is reflected in their record, the following documents or notes would typically be included:

• Documentation of the consent process in accordance with CPSO’s Consent to Treatment policy, including a record of any forms that were used
• Pre-procedure assessment
• A copy of the completed Surgical Safety Checklist
• The Anesthetic/Sedation Record
• Discharge summary, where applicable
• Any adverse event reports, as required by CPSO.

Endnotes

^1. For more information see the Canadian Anesthesiologists’ Society Guidelines to the Practice of Anesthesia.