Question

If you want to review a chart, but not create an Anesthesia Record, what steps would you follow? Choose all that apply:

a) Open the patient's chart in the EHR system.
b) Access the Anesthesia Records section.
c) Review the patient's medical history and notes.
d) Document any relevant observations or findings.

Answer 1

To review a chart without creating an Anesthesia Record, open the patient's chart in the EHR system and review the medical history and notes. Do not access the Anesthesia Records section or document unless required.

Step-by-step explanation:

If you need to review a chart without creating an Anesthesia Record, you should follow these steps:

• Open the patient's chart in the EHR system.
• Review the patient's medical history and notes.
• Since you are not creating an Anesthesia Record, it is not necessary to access the Anesthesia Records section or document any relevant observations or findings unless required by your specific workflow.

Context in Medical Settings

During a surgical procedure, it is critical for team members to review important information about the patient. This includes verifying the patient's identity, surgical site, and procedure, as well as discussing critical steps and anticipated challenges for the surgery and anesthesia. This is part of ensuring high-quality patient care and safety. After reviewing the medical records, healthcare professionals may proceed with their respective preoperative checks.