VN1 - test 1

Anesthesia Definition

Without feeling/sensation

General Anesthesia Definition

A safe & reversible state of:

· Unconsciousness

· Immobility

· Muscle Relaxation

· Analgesia

General Anesthesia:

Safe = what?

Produces minimal stress & adverse effects

General Anesthesia Phases

· Pre-Anesthetic

· Premedication

· Induction

· Maintenance

· Recovery

Pre-anesthetic Phase

intake, prep

Premedication Phase

sedative, usually by injection to go from fully-awake to sleepy & groggy

Induction Phase

from premedication, into stage 3 fully-unconscious

Maintenance Phase

use of inhalants to keep patient unconscious

Recovery Phase

removal of inhalants

Light Stage 3 Anesthesia

Stage 3 Plane 1

Surgical Anesthesia

Stage 3 Plane 2

Deep Stage Anesthesia

Stage 3 Plane 3

Pre-Anesthesia Technician Roles

· Medical record & intake

· Patient history & physical exam

· Pre-anesthetic procedures

Pre-Anesthetic Procedures

· Ensure all equipment is in working order

· Pre-anesthetic testing, care, support, stabilization

· Lay out supplies

· Place IV catheter

· Administer/know preanesthetic drugs

· Monitor patient

Medical Records: Components

· Intake Form

· Client Consent Forms

· Estimate & Release Forms

· Physical Examination Form

· Diagnostic Reports

· Anesthetic Record & Recovery Sheet

· Medical Progress Notes (SOAP)

· Treatment Sheets

· Discharge Statement

· Radiographs & Surgical Reports

· Surgery/procedure/controlled substance/radiology log

Medical Record: Purpose

· Supports medical care & communication

· Supports business, legal, insurance, accreditation & regulatory activity

VCPR

· Veterinary Client Patient Relationship

· Medical records must be maintained when a VCPR exists

VCPR: Vet assumes responsibility for...?

Client agrees to...?

· patient

· follow recommended care/treatment

VCPR: Vet knows the animal & its condition how?

examination or other timely medical visits to facility

VCPR: In case of need, the vet is...?

available or has arranged for emergency coverage for animal in case of need

VCPR: Vet provides...?

oversight of treatment, compliance & outcome

VCPR: What is maintained?

Patient records

Informed Consent

client's agreement to allow something to happen: ie medical, surgical or diagnostic procedure

Informed Consent: Client/representative must receive

Verbal & written education on any diagnosis, prognosis, treatment options, risks & costs

Informed Consent: Client Age

Must be >18 to sign and authorize anything

Owner of medical records

Practice & practice owner

NYS Medical Record Storage Time

3 years after the animal has last been seen

NYS Medical Record Storage Time: Controlled Substances

5 years after the animal has last been seen

Medical Record Confidentiality Exceptions

· Client Consent

· Court order

· Reportable disease

Medical Record Copies

Vet is obligated to provide these upon written client request

Medical Record Types

SOVMR

Source-Oriented Medical Record

POVMR

Problem-Oriented Medical Record

SOVMR: Organization

· Chronological

· Information grouped by subject matter

SOVMR: Sections

· Lab report Section

· Anesthesia & Procedures Section

· Progress Notes in paragraph format section

POVMR: Organization

Information grouped by medical problem

POVMR: Key Features

· Patient Database

· Problems listed in a "master problem list" at beginning of the record

· Progress notes written in S.O.A.P format for each problem

Signalment

· Age

· Sex

· Reproductive status

· Species

· Breed

Reproductive status is written as

M, N, FS, MI, M, F, FI

POVMR: Patient Database

· Client & patient names

· ID: microchip, tattoo, hospital ID

· Color & Distinctive markings

· Vaccine/Medical History

POVMR: SOAP

· Subjective

· Objective

· Assessment

· Plan

Subjective

Cannot be measured

Objective

Can be measured

Assessment

Analysis of Subjective + Objective

Plan

Course of action, game plan based on findings

Subjective parameters

· Body Condition Score

· Mentation/Level of consciousness

· Pain

· Gait & posture

· FAS

Mentation

· Bright Alert Responsive (BAR)

· Quiet Alert Responsive (QAR)