The evolution of medicine, and in particular dental anesthesia, has been linked to the evolution of pharmacology and technology. The recording of a general anesthesia encounter is much more complex than an office visit. It involves a preoperative evaluation, medication recording and the frequent sampling of physiologic data in real time. The charge of the record is to accurately and comprehensively capture the patient experience. The evolving challenges include solving the interoperability issues in EHRs, meeting the patient safety standards of care, exceeding the ever-increasing professional liability standards and ultimately submitting data to patient safety registries to validate the long-established model of office anesthesia.
Learning Objectives:
At the conclusion of this presentation, participants should be able to:
Summarize the evolution of the written record to include contemporary physiological measurements.
Describe the unique requirements of an office-based anesthesia record.
Explain the parameters that are currently required in a modern digital anesthesia record.
Define how an office-based anesthesia record can be leveraged to help maintain a controlled substance compliance program.
Discuss the role of the digital retrospective chart review to improve patient safety.
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