Review Note
Last Update: 07/07/2024 08:57 PM
Current Deck: MSA 460 Final - Community MASTER
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Front
What to include in the narractive? what are the pitfalls?
Back
-document a chronological description of the anesthetic and include anything that is not otherwise represented in the chart
ex: 0645 Pt ID’d chart reviewed, 18ga IV started L hand, 0714 to OR#5 standard monitors applied, 0722 uneventful IV induction, DL x 1 atraumatic 7.0 ETT taped @ 21cm @ lip, BL UEs <90’ secured on arm-boards, PPP & checked. Incision @ 0743. 0834 Pt SV, responsive to command, BL hand grips adequate, mouth suctioned, pt extubated, SV well on 10L/m SFM, VSS, to PACU w pulse ox, report to RN
Pitfalls: be factual, avoid adjectives (like "good" or "smooth"), too much vs. not enough (goal is to be able to look at your record and recreate what happened even if you weren't the one who did the procedure)
ex: 0645 Pt ID’d chart reviewed, 18ga IV started L hand, 0714 to OR#5 standard monitors applied, 0722 uneventful IV induction, DL x 1 atraumatic 7.0 ETT taped @ 21cm @ lip, BL UEs <90’ secured on arm-boards, PPP & checked. Incision @ 0743. 0834 Pt SV, responsive to command, BL hand grips adequate, mouth suctioned, pt extubated, SV well on 10L/m SFM, VSS, to PACU w pulse ox, report to RN
Pitfalls: be factual, avoid adjectives (like "good" or "smooth"), too much vs. not enough (goal is to be able to look at your record and recreate what happened even if you weren't the one who did the procedure)
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