Customize how you want anesthesia records to record and display specific types of information and record data from the vital signs monitor during surgery.
Select Tables > Practice > Charting Preferences. The Charting Preferences window is displayed.
Select Anesthesia Records, and then click Customize. The Customize Anesthesia Record window is displayed.
Select the tab to configure.
Use the Pre-Op Evaluation tab to enable the recording of Vital Signs, Pre-Operative Medications, Lung and Heart measurements, Body and Arm Positions, Eye Care actions, Dental Status, Body Mass Index, Airway conditions, and the Mallampati Score feature for the patient's palate.
Select the Enable checkbox for each set of data you want to record. The options underneath become active for selection. Deselect the Enable checkbox for sections you do not want to include in your default anesthesia record.
In each enabled section, select or enter the data you want to record. Each time a new anesthesia record is created, these default values are checked, but can be changed for each individual record.
Click Surgery Info to continue.
Use the Surgery Info tab to enable the recording of Universal Protocol, Monitors, Airway settings, Breathing Circuit details, Anesthesia Techniques, Chronological, and IV Details.
Select the Enable checkbox for each set of data you want to record. The options underneath become active for selection. Deselect the Enable checkbox for data you do not want on the record.
In each enabled section, select or enter the data you want to record.
Click Post-Op Evaluation to continue.
Use the Post-Op Evaluation tab to enable recording of both Post-Op and Discharge Vital Signs, Complications, and additional discharge details.
Select the Enable checkbox for each set of data you want to record. The options underneath become active for selection. Deselect the Enable checkbox for data you do not want on the record.
In each enabled section, select or enter the data you want to record.
Click Other to continue.
The Other tab contains tools for verifying the patient's condition for discharge.
In the Other tab, select Enable Aldrete Score to activate this feature.
Select Enable Discharge Questions to use the listed questions as discharge criteria. These questions are defined on the Discharge/Verify tab of the Charting Preferences window.
Select Enable Verifications, and then select the activities the patient should be able to perform.
Use the Additional Information area to enter any other instructions or discharge criteria you want used and recorded for the patient when being discharged.
Click OK.
Before you can document the administration of drugs for an anesthesia record, you must add the drugs, categories, and drug panels to the database. You can then select the drugs and indicate dosages on the Surgery - Vitals portion of the patient's anesthesia record.
Perform the following three tasks to add drugs and drug panels to the database:
Create drug categories.Create drug categories.
Select Tables > Drugs & Prescriptions > Drug Categories. The Drug Category Search window is displayed.
Click New. The Create Drug Category window is displayed.
Enter the Code for the new category, if applicable, and the Category Name.
Click Ok.
Add drugs to the database.Add drugs to the database.
Select Tables > Drugs & Prescriptions > Drugs. The Drug Search window is displayed.
Click New. The Create Drug Item window is displayed.
In the Category field, use the drop-down list to select the category for the drug.
Enter the Code for the new drug, if applicable, and the Drug Name.
Enter the Default Dosage for the drug, and use the drop-down list to select the appropriate Dosage Units.
Click Ok.
Create drug panels.Create drug panels.
Select Tables > Drugs & Prescriptions > Drug Panels. The Drug Panel Search window is displayed.
Click New. The Create Drug Panel window is displayed.
In the Description field, enter a unique name to identify the drug panel.
Add the drugs that comprise this panel by clicking Add. The Add Anesthesia Drug (Agent) window is displayed.
Use the drop-down lists to select a category, and then the specific drug.
Enter the appropriate dosage for the drug, and specify the units for the dose.
Click OK. The drug is added to the list in the Create Drug Panel window.
Continue adding the drugs to the drug panel, and then click Ok.
Always double-check your entries when creating drug panels.