Entry Level COP7

COP 7: Documented procedures guide the administration of anaesthesia.

a.    The procedure for Administration of Anaesthesia is: In order to achieve patient safety, the Anaesthetist is responsible for determine the procedure for administration of anaesthesia.

b.   Pre-anaesthetic evaluation of the patient: A pre-anaesthesia evaluation allows for the development of an anaesthesia plan that considers all conditions and diseases of the patient that may influence the safe outcome of the anaesthesia.

c.    Prescribing of anaesthesia plan: The anaesthesiologist is responsible for prescribing an anaesthesia plan aimed at safety of each patient. The anaesthesiologist discusses with the patient (when appropriate), the anaesthesia risks, benefits and alternatives.

d.   Pre Anaesthesia evaluation: An Anaesthesiologist shall be responsible for determining the medical status of the patient and developing a plan of anaesthesia care. The Anaesthesiologist is responsible for: Reviewing the available medical record; Interviewing and performing a focused examination of the patient to discuss the medical history, including previous anaesthetic experiences and medical therapy; Assess those aspects of the patient’s physical condition that might affect decisions regarding pre-operative risk and management; Prescribing and reviewing of available tests and consultations as necessary for administration of anaesthesia care; Prescribing appropriate pre-operative medications.

e.    Anaesthetist obtains consent from the patient after briefing him/her about the advantages, disadvantages the risk involved.

f.     Intra Procedural Monitoring: Immediate review prior to initiation of anaesthetic procedures: Patient re-evaluation; Check of equipment, drugs and gas supply; Monitoring of the patient (e.g., recording of vital signs); Amounts of drugs and agents used, and times of administration; The type and amounts of intravenous fluids used, and times of administration; The technique(s) used; Unusual events during the administration of anaesthesia; The status of the patient at the conclusion of anaesthesia.

g.    Post-surgery the anaesthetist determines whether the patient can be sent out of OT or needs enhanced level of care. Suitable record in the patient file is made.