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Documentation : Medical Care

Anaesthesia documentation is a necessity to meet required standards for care and compliance.
Aisthesis monitors this for all providers across all regions. The results are used for:

  • Providing educational feedback
  • Demonstrating compliance to our customers and inspecting agencies
  • 20% of the provider performance scoring for the bonus plan.

Results

Fallgrph

These are the Fall results.  You have a ranked position on the graph and you can find your rank by Email. Your quartile will add points towards the final 2016 Bonus.

The documentation review process is :

 

Legibility

Although this is necessarily somewhat subjective, it is a required element for all of the inspecting agencies. If your co-workers can’t easily decipher what you have written then it is time to clean it up.

Required elements of care:

These are the fundamentals of the work we do as required by external agencies. We are required, for example, after interviewing the patient, to document an informed patient consent with a plan for anesthesia care and a discussion of common risks including an assessment of ASA physical status. We must list all patient medications and medication allergies, assess the airway, perform a directed physical exam, and obtain a set of Vital signs before each anesthetic.   On arrival in recovery we must again obtain a set of Vital signs, including level of consciousness and respiratory status verifying the patient is safe to be left, before recording a report given to a PACU nurse.

Required elements of documenting an anesthetic

These are the basics of demonstrating our delivery of anesthesia care during the case. Requirements include regularly recording all vital signs from beginning until the patient arrives in PACU, documentation of medication doses and times, noting iv fluids and any other noteworthy events.

Careful completion of one of our new anesthesia records is the best way of making sure you are meeting all the requirements of these 2 sections.

 

Review Method

The scoring uses weighting from the external agencies. The details and the grid are Here as a PDF.

FinalFall2016Tool

Every provider in Safe Sedation or PAC is involved. We obtain 5 random scans of the billing copies of records for each provider, from differing days and differing sites over a 6 month period.

 

Aisthesis Core Values
Professional Care. Personal Touch.
Consistent Providers. Quality Care.
Data Driven Solutions. Optimal Operations.