Documenting the assessment and the pain round
aurii drafts the pre-anaesthetic assessment, the acute pain round note and the letters to the surgeon and the GP from one spoken review.
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Spoken in the assessment clinic
A pre-anaesthetic assessment three weeks before an elective list, on a synthetic patient.
"Pre-anaesthetic assessment for the elective knee replacement in three weeks."
"He has hypertension and treated obstructive sleep apnoea, uses the device nightly, and has no ischaemic symptoms."
"Airway is Mallampati two, good mouth opening, full neck movement, and he had an uneventful general anaesthetic for a hernia in twenty twenty-two."
"Exercise tolerance is two flights of stairs without stopping, and the last echocardiogram was normal."
"Plan a spinal with sedation, continue the antihypertensive on the morning of surgery, and bring the device in with him."
"Letters to the surgeon and to his GP with the plan and the fasting instructions."
Pre-anaesthetic assessment for elective total knee replacement in three weeks. Hypertension and treated obstructive sleep apnoea, nightly positive airway pressure. No ischaemic symptoms.
Mallampati 2, good mouth opening, full neck movement. Uneventful general anaesthetic for hernia repair in 2022.
Two flights of stairs without stopping. Most recent echocardiogram normal.
- Spinal anaesthesia with sedation
- Continue the antihypertensive on the morning of surgery
- Bring the positive airway pressure device to hospital
- Letters to the surgeon and the GP with the plan and fasting instructions
Illustration of the drafting view.
Either side of the operation
aurii drafts the pre-anaesthetic assessment as it is spoken and the acute pain round note at the bedside. The assessment reaches the surgeon and the ward as a signed letter before the list; the pain round carries the block or infusion status and today's change. The anaesthetist signs before anything leaves.
Documents from one assessment
Billing items are captured at the bedside against the episode, for your practice to claim. Billing.
Starter templates an anaesthetic service draws on
Your letterhead and section order, set once, on every draft. The template set.
Correspondence before the list
aurii drafts both letters from the assessment: the anaesthetic plan to the surgeon, the medication instructions for the days before surgery to the GP. The anaesthetist signs both.
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