Practice Consideration

Documentation (Practice Consideration)

Last AANA revision: 2023

The anesthesia record is a legal medical document. Required elements: pre-anesthesia, intraoperative, post-anesthesia phases. Drug doses, vital signs (every 5 min minimum), interventions, fluid totals, ASA score, airway, line placement, complications.

Key points

1.Vital signs documented at minimum every 5 minutes
2.Pre-induction equipment check signature
3.All medications: drug, dose, time, route, response
4.Adverse events documented with timeline + interventions
5.Handoff: patient, procedure, anesthetic, IVs, fluids in/out, complications, postop plan

This is an exam-prep summary, not a substitute for the full AANA document. Read the source at aana.com for authoritative wording. Education only.