How to Create an Anesthesia Record – Carestream Dental

Note: This feature is available for practices that have Oral Surgery features enabled.

Sensei Cloud provides an Anesthesia Record where you can record data related to the patient's condition before, during, and after a procedure in which anesthesia is administered.

Use the Clinical Chart (EMR) interface to view and create anesthesia records. There are five tabs for data entry to correspond with the process from beginning to end.

To create an Anesthesia Record:

From the Patient tab, select Clinical > Clinical Chart (EMR). The appointment is displayed in the panel.
On the right side of the appointment line, next to Manage Appointment, select Add to Chart > Anesthesia Record. The Anesthesia Record entry panel is displayed, with the General Information tab selected.
Note: You cannot add an Anesthesia Record until a procedure has been added to the appointment.

To edit an Anesthesia Record:

Existing records for an appointment are displayed and summarized as a line item (panel) for the appointment date. To access and edit the interface, click the pencil icon. The record is opened for editing. You can also use the trash icon to delete/remove a record from the chart; a record of its creation and deletion is retained for audit purposes.

Recording General Information

When you add or edit an Anesthesia Record, the General Information tab is displayed first with basic information entered.

To complete the General Information tab:

Under BMI Information, enter the patient's Height (in/cm) and Weight (lbs/kg). The BMI is calculated automatically.
Note: Once entered, height and weight are automatically calculated for both systems of measure. View or set your practice default system by selecting Administration > Practice Settings > Clinical Rules.
Under Additional Information, select Consent Signed if you have this signed form.
For Escort, select the Escort type (relationship) and enter the name of the person responsible for the patient after the surgery.
For NPO, enter the number of hours since the patient has had food or water.
In the Record Overview section, scheduled procedures are included in the Procedure Code list.
Note: You can select a code from the list and enter additional details in the Procedure Description field, if desired.
In the Surgery Details section, you can enter the patient's ASA class, Surgeon, Anesthesiologist/CRNA, RN, and/or Assistant(s) if they are stored in the system.
Click Update Record. The information is saved, enabling you to move to the next tab.

Note: It is recommended that you save the information you enter on each tab before moving to the next tab. Since no fields are required, you can return and enter additional information later.

Recording the Pre-Op Evaluation

Use the Pre-Op Evaluation tab to record pre-operative vital signs and other data relevant to the patient's condition and preparation for the surgery. To enter pre-op data:

From the Anesthesia Record, select the Pre-Op Evaluation tab. The data fields are displayed.

Note:
--You can also use a connected monitor to record a single set of readings of the pre-op vital signs. To do so, select a connected monitor from the drop-down list and click Capture. The vitals are recorded and immediately populate.
--If a monitor is turned off or unplugged, it displays as Disconnected. See How to Set Up Vitals Monitor Integration for more information.
Enter the data you collect on the patient's condition prior to surgery, including what pre-op medications were given and when, dental issues, eye protection, and any additional comments.
Click Update Record. The information is saved, enabling you to move to the next tab.

Recording Surgery Info

Use the Surgery Info tab to document how the anesthesia is to be delivered and managed during the surgery. To enter these details:

From the Anesthesia Record, select the Surgery Info tab. The data fields are displayed:
Enter the data for the equipment, procedures, and techniques used in this surgery. You can also enter the estimated blood loss (EBL) and any relevant notes.
Note: If your monitor, delivery method, etc. are not in the list, select Other and use the entry field to record it.
Use the Notes section to enter additional comments.
Click Update Record. The information is saved, enabling you to move to the next tab.

Recording Surgery Vitals

Use the Surgery Vitals tab to record data gathered during the surgical procedure. It includes a Time Out feature that prompts you to review patient details before recording details in the tab.

The Event Log tracks entered details, enabling you to record multiple sets of readings throughout the procedure. When you click Save, the entered readings from that panel are added to the log, along with the time saved. The fields in the panel are cleared, enabling you to record more readings.

To record vital information during the surgery:

From the Anesthesia Record, select the Surgery Vitals tab. The data fields are displayed, but grayed out.
Click the Time Out button. The Time Out Overview window is displayed.
Review the information, and then click Time Out Reviewed. The entry fields become editable.
Note: You cannot complete or update the data on this tab until the Time Out review is completed.
For Anesthesia and Surgery, use the Start and Stop buttons to record the current time for each.
Note: You may need to verify/edit the automatic entry for your time zone. You also have the ability to type military time in these fields and the system automatically updates this information (e.g., 13:00 updates to 1:00 PM).
Under Vitals, select Manual to enter the patient's vitals manually, or select Monitor to use an integrated vitals monitor.
--Manual: Enter the vitals and then click Save. The reading is added to the Event Log and the fields are cleared, enabling you to enter additional readings. Note: Click Reset to reset the Time field for new entries.
--Monitor: Select a monitor from the drop-down list, and click Start to begin recording. See How to Record a Patient's Vital Signs Using a Connected Monitor for more information.
Enter the patient's ECG as per your procedures.
Note: You have the ability to take ECG snapshots from a connected vitals monitor during surgery by clicking Capture Snapshot. See How to Record a Patient's Vital Signs Using a Connected Monitor for more information.
If administering Fluids, record the Type and Volume amount.
Enter the Drug Type, Dose, Dosage Units, Quantity, and Time for an administered drug, and then click Save. The reading is added to the Event Log and the fields are cleared, enabling you to enter details for additional drugs.
Note: Click Reset to reset the Time field for new entries.
Enter the Gas Type, Units, and On/Off times for administered gas, and then click Save. The reading is added to the Event Log and the fields are cleared, enabling you to enter details for additional gas types.
Note: Click Reset to reset the Time field for new entries.
Enter the time when the patient is (or will be) moved to recovery in the Time to Recovery field.
Use the Notes field to enter any notes about the surgery, patient condition, drug status, etc.
Click Update Record. The information is saved, and the Stop times are automatically entered into the Event Log.

Recording the Post-Op Evaluation

Use the Post-Op Evaluation tab to document the patient's readiness for discharge. To record the post-op evaluation:

From the Anesthesia Record, select the Post-Op Evaluation tab. The data fields are displayed.
In the Aldrete Score column, select the appropriate option in each category. The Total Aldrete Score is calculated for you.
Enter the Discharge Details and Instructions Given, as well as the name of the discharging Staff member and Post-Op Medications.
Enter a final set of Vital Sign readings, if desired, and any additional Notes to include in the record.
Note: You can also use a connected monitor to record a single set of readings of the post-op vital signs on demand. If you select a monitor in another tab of the anesthesia record, the selected monitor is auto-selected in the other tabs.
Click Update Record. The information is saved.
Note: You can return to any of the previous tabs to edit or enter additional information as needed.

Returning to the Clinical Chart (EMR)

After you save the Anesthesia Record, under Actions, select Back to Clinical Chart (EMR). The Anesthesia Record is displayed as a panel on the appointment date.

From here, you can:

Select the printer icon to preview and print the record. All completed fields are present; uncompleted fields are omitted. You can print or save the file as a PDF in your Downloads folder to be emailed or saved elsewhere.
Select the pencil icon to open the record and edit details.
Select the trash icon to remove the record from the appointment.

For more information, see Sensei Cloud Oral Surgery Feature Overview.