2004-2005

Address and Phone List

0000- A faculty anesthesiologist was present for all critical portions of the procedure including induction, intubation or other airway management procedure,  invasive procedures and emergence in accordance with CMS teaching rules.

0001- Anesthesia machine and monitors checked.

0002- Patient identified, NPO status checked, chart reviewed, medications and allergies reviewed and discussed.  Risks, benefits and alternatives to anesthesia discussed.

0003- Patient to OR.  Monitors on.

0004- The patient was reassessed immediately prior to beginning the anesthetic procedure.

0005- Preoxygenation.  Routine uneventful induction, mask ventilation and intubation.  ETT cuff inflated to just above leak.

0006- ETT secured.  Eyes taped for protection.  Pressure points padded and checked. Extremities, ears and eyes checked for proper and secure positioning.

0007- MAC procedure planned.  Supplemental oxygen started.  Sedation started.

0099- Done.  Suctioned, extubated awake, spontaneous ventilations.  To PACU with mask oxygen.

0100- Patient eyes, ears and extremities checked for proper padding and positioning.

1000- Post operative Pain Management management requested by surgeon.

1000- The patient (or guardian) gave informed consent to proceed with regional block.

1001- Ultrasound used to identify anatomy.

1002- Sterile Chloraprep and drape.  Local with lidocaine.

1003- Sterile prep with alcohol.

1004- Catheter inserted and secured.

1005- Patient instructed for home infusion of local anesthetic.

1006- Paresthesias used to identify injection site.

1007- Paresthesias resolved.

1008- Nerve stimulator used to identify injection site.

1009- No paresthesias.

1010- Local infiltration by surgeon.

1110- Interscalene block.  Interscalene groove identified.  21 G needle inserted into groove.  Local anesthetic injected.  Aspiration neg for blood.

1111- Interscalene block w/cath.  Interscalene groove identified.  18 G IV catheter inserted into groove.  Local anesthetic injected.  Aspiration neg for blood.

1120- Axillary block.  21 G needle.  Local anesthetic injected. 

1130- Femoral nerve block.  18 G IV catheter lateral and deep to fem art.  Local anesthetic injected.  Aspiration neg for blood.

1140- Pop fossa block.  21 G IV catheter inserted between biceps femoris and semimembranous m.  Local anesthetic injected.  Aspiration neg for blood. 

1141- Saphenous nerve block.  Saphenous vein identified.  Local anesthetic injected SQ around vein.  Aspiration neg for blood.

1150- Bier block.  IV catheter placed. Limb exsanguinated, proximal tourniquet inflated, local anesthetic injected.

2000- Patient positioned.  Pressure points padded and checked.

2001- Patient positioned supine, arms carefully positioned and secured, elbows padded.

2002- Patient positioned prone, arms carefully positioned and secured, elbows padded.  Ears checked and padded.  Eyes checked, secured, dependent and without external pressure.

2003- Patient positioned sitting, arms carefully positioned and secured, elbows padded.

2004- Patient positioned left lateral decub position.  Ax roll in position.  Arms padded. Knees and feet padded.  Eyes and ears checked and protected. 

2005- Patient positioned right lateral decub position.  Ax roll in position.  Arms padded. Knees and feet padded.  Eyes and ears checked and protected.

Arterial line started

Artifact, agent concentration

Artifact, arterial line

Artifact, CVP

Artifact, EKG

Artifact, NIBP

Artifact, PAP

Artifact, pulse oximeter

Artifact, temperature

Artifact, unspecified

Artifact ventilator parameter

Assisted ventilation

Central venous access, sterile prep and drape, Seldinger technique

Clamp off

Clamp on

Comments:

Controlled ventilation

CRNA assuming care of patient

CRNA signing out

End of all Surgery Related Actions

End of Anesthesia Care

End of Printed Holding Record

End of printed Intra-op Record

End of Printed Post-op Record

End of Surgery

Extubation

Faculty assuming care of patient

Faculty signing out

Fluid warmer started

Forced air warmer

Induction

Intubation

IV started in holding area

Laryngoscopy, Grade I atraumatic intubation with direct visualization of cords, bilateral breath sounds, CO2 confirmed, endotracheal tube taped and secured

Laryngoscopy, Grade II atraumatic intubation with visualization of arytenoids, bilateral breath sounds, CO2 confirmed, endotracheal tube taped and secured

Laryngoscopy, Grade III epiglottis seen, no other laryngeal structures visible, intubation  successful, bilateral breath sounds, CO2 confirmed, tube taped and secured

Laryngoscopy, Grade IV difficult intubation, no epiglottis or laryngeal structures seen, intubation successful, bilateral breath sounds, CO2 confirmed, tube taped and secured

Nasogastric tube, size:

Orogastric tube, size:

PACU vital signs:  BP, P, R, SpO2, Temp

Patient arrives in Operating Room

Patient arrives in Recovery Room

Patient enters OR

Patient exits OR

Patient is ready for Surgery

Patient leaves Operating Room

Patient leaves Recovery Room

Patient position changed

Pre-use Checkout

Report given to PACU/ICU nurse

Resident assuming care of patient

Resident signing out

Reversal

Scheduled case end

Scheduled case start

Spontaneous airway without obstruction in PACU

Spontaneous ventilation

Start of Anesthesia Care

Start of Printed Holding Record

Start of Printed Intra-op Record

Start of Printed Post-op Record

Start of Surgery

Suctioned & extubated in PACU, stable airway in PACU

Tourniquet Off

Tourniquet On

Transported to PACU per OR nursing documentation

Wound dressing