Content item

Rationale

Verification of “nil per os” status

A historical feature that must be
verified on the day of surgery

“Absence of peripheral nerve stretch verified”

A prompt to document the careful positioning and padding of extremities

Prompt for “Ultrasound Guidance” when used for central venous access

The use of this tool decreases risk and should be documented.

Accurate description of ventilatory modes over time, including documentation of tidal volume when pressure controlled ventilation is used

Ventilatory modes may be changed during the course of the anesthetic, a reality for which the anesthetic record must allow.  In the case of a handwritten record, documentation may promote clinician awareness of this important physiological variable.

Airway pressure

Important physiologic variable

Fluid management summary box

Important clinical information which  may be difficult to interpret from grid portion of record

Intra-operative laboratory results box


Promotes review of laboratory results and presents results and trends visually to the anesthesiologist.

Regional technique details box:  includes prompts for needle type and sizes, precautions, drug types and doses;  include absence or occurrence of bloody tap

Promotes completeness and serves as an easy reference for other health care professionals caring for the patient postoperatively (e.g. acute pain service, thrombosis team).

Table 1: Selected Content Items for Intra-operative Phase.