Are detailed logs made during surgery?
December 13, 2012 12:28 PM   Subscribe

Are there any kind of notes taken during a medical procedure, or is it all after-action report-type stuff? If I wanted to know just how much of each drug I was given during anesthesia (for instance) for a procedure months or years ago, would it be somewhere in my record that I could request?

At one point, I requested records to bring with me when I transferred doctors, and they included surgeon's and pathologist's reports from a surgery I had. They were mostly summaries, and didn't include any numbers as I recall, just a description of procedures.

Here at in-center hemodialysis, all relevant numbers are recorded into the system for each treatment, and nurses/techs make notes when anything happens, at regular intervals, and at the start and end of treatment.

Would it be likely that similar notes would be taken and kept during a procedure in a hospital, e.g. "11:42 - patient showed skeletal muscle activity, X mg of A were administered." etc.?
posted by WasabiFlux to Health & Fitness (8 answers total) 1 user marked this as a favorite
The sort of information you are asking about would be in the anesthesia record. It's generally set up like a flow sheet, with vital signs charted periodically, and medication doses. It's not as much of a narrative as your example above.

It would be in your hospital chart at the facility where you had surgery. If you contact medical records there they should have a procedure for releasing them.
posted by maryrussell at 12:45 PM on December 13, 2012

Absolutely. It's a JCAHO requirement, I believe - all hospitals I've worked at record such things quite carefully. But those records are not necessarily a part of the record that would be sent to another person who is requesting medical records, because usually when you make a medical records request (as a physician, that is), you have to mark off what you're looking for, i.e. blood work, imaging studies, consultations, H&Ps, etc. - the thing you want is more a part of the nursing notes, which don't tend to be that useful for other physicians to look at.
posted by treehorn+bunny at 12:47 PM on December 13, 2012

re: the difference between my reply and maryrussell's: if it was a procedure in the OR with anesthesia, it is part of an anesthesia record that the anesthesiologist or CRNA fills out. If it was a procedural sedation done on an outpatient basis (like we do in the ER, or other procedural locations), the nurse tracks the flowsheet while the physician is doing the monitoring/ordering, and sometimes doing the procedure as well. But either way the format is as she described.
posted by treehorn+bunny at 12:50 PM on December 13, 2012 [1 favorite]

It probably varies some by what kind of procedure and where you're having it done, but where I work, if you're having full on surgery, there are a ton of things recorded by nursing and anesthesia during the procedure. Here they would definitely record times and dosages of anything administered, as well as vitals, equipments and techniques used, positioning, fluids in and out...pretty much anything you can think of.

Here that would be referred to as the "Anesthetic Care Record".
posted by ghharr at 12:51 PM on December 13, 2012

I'd be very interested in requesting, just for myself, all of my records from everywhere, but at 25 cents per page and 7 different facilities, I couldn't afford that; so it's nice to know what to ask for, at least.

Most recently, I'm curious whether the anesthesiologist misestimated and knocked me out when I wanted conscious, "mostly-aware" sedation; or if I just forgot the entire thing until they wheeled me out, as Versed tends to cause. But I'd also want to know what was different with my third surgery that I felt so terrible afterward that they had to keep me overnight when it should've been outpatient. You know, just little things.)

Thank you, all.
posted by WasabiFlux at 12:56 PM on December 13, 2012

Most recently, I'm curious whether the anesthesiologist misestimated and knocked me out when I wanted conscious, "mostly-aware" sedation; or if I just forgot the entire thing until they wheeled me out, as Versed tends to cause.

While the anesthesia record will likely reflect how much meds you got, in my experience as a physician who performs procedures and provides moderate-to-deep sedation, there will probably be no way to know whether or not you were given moderate, or "mostly aware" sedation. This tends to be defined subjectively based on the patient's degree of responsiveness to stimulation, and is rarely well-documented beyond simple statements affirming that someone received "moderate" or "twilight" sedation. Quite commonly I can have involved conversations with a patient right after a procedure, where they will be able to follow commands, and may even look almost completely alert. A few hours later, they remember absolutely nothing. That's the magic of anterograde amnesia and Versed.

The record may however offer other details that might help answer your question: in particular, it is likely to have your vital signs documented throughout the procedure so you may be able to tell whether your blood pressure, heart rate, respiratory rate, oxygen levels, or carbon dioxide levels (if measured) were out of whack.
posted by drpynchon at 1:40 PM on December 13, 2012 [2 favorites]

Seconding drpynchon who of course is right on the money.

The only thing I would add is that if a physician like him or I screws up and gets a person to a general anesthesia level of sedation (which is what you might mean when you say "knocked out", rather than what we understand as "deep sedation"), the difference is clear at that point, because the person stops breathing and we have to do something to intervene.

If the procedure is not very painful then many people rest comfortably through it even if they are only lightly sedated, even though they still would respond appropriately if you asked them "how are you doing?" If the procedure is very painful then the patient may be literally screaming or shouting during the procedure but still have zero memory of it and be smiling about 15 minutes later after the meds wear off or asking "did you do it yet?" because they don't remember a thing. The magic of Versed, indeed.
posted by treehorn+bunny at 9:23 PM on December 13, 2012

And I should clarify that regardless of whether the patient is resting comfortably or is shouting, most such procedures I've done are still just documented as "moderate sedations" with no comment on what the patient's reactions were. "Patient tolerated the procedure well/fair/poor" is one checkbox in our sedation record that is usually the only clue to this aside from the number of doses and amounts of medications that were used.
posted by treehorn+bunny at 9:27 PM on December 13, 2012

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