Anesthesia Solutions of Mobile Providence Hospital Anesthesia Billing Record Attention: Dotted areas created for VitalMed use. ❏ MDA Only

MDA 1 _______________ MDA 2 _______________ MDA 3 ____________________ Relief Given By ________________ TIme in: ______ Time Out: _____(relief must be noted in anes. recrd.)

❏ MDA/CRNA ❏ CRNA Only

CRNA 1 _______________ CRNA 2 _______________ CRNA 3 ____________________ Relief Given By ________________ Time in: ______ Time Out: _____(relief must be noted in anes. recrd.)

Date of Service: ________________________ Admit Status (Circle One): Outpatient ()

99135

Utilization of Controlled Hypotension − complicating anes

93503

Swan−Ganz

99140

Emergency Complicating 93312 Anes.

36620

Arterial Line

62273

31500

Emergency Intubation

Blood Patch

93315

TEE probe placement: for cardiac anomaly

Evaluation and Management Service (Documentation MUST be attached) CPT−Mod

Other Procedure(s) (Include Details)

CPT−Mod CPT−Mod CPT−Mod

Post Operative Pain Management

CPT−Mod Procedure: ____________________________________________ Was this service for: ❏ Post op pain only ❏ Anes serv/ post op pain ❏ Other ______________________ ❏ Daily Mgmt of continuous epi/spinal catheter (01996): Date(s):__________________

ICD−9:

ANES0002

r*OP5028*r

PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000

OP5028

Universal Protocol for Surgical/Invasive Procedures

Location (Surgery/procedure area/unit):

Date:

Procedure:

Pre−operative Verification

Time Out Immediately Prior to Procedure Initial

(Physician must be present)

Correct Patient

Correct Patient

Correct Procedure

Correct Procedure

Correct Site:

❏ Left ❏ Right ❏ NA

O P Correct Position

Site Marked by Physician Medical Records and Imaging Available and Verified

S S

Informed Consents

❏ Yes History and Physical ❏ Yes Anesthesia Evaluation ❏ Yes Lab X−rays

❏ Yes ❏ Yes

A P

Initials/Signature

❏ NA

❏ NA ❏ NA

Initials/Signature

T R

Correct Site:

Correct Side:

Initial

Correct Side: ❏ Left ❏ Right ❏ NA

Correct implant or special equipment available Prophylactic antibiotic received within ❒ Yes ❒ No one hour prior to surgical incision* ❒ NA Time: _________ Participants: Physician: Anesthesia:❏ NA Nurse/Tech: Nurse/Tech:

Initials/Signature Initials/Signature

*Antibiotics are mandatory for the following procedure: Head and neck procedures (incisions through oral or pharyngeal mycosa) Orthopedic with Implants Elective Craniotomy Hysterectomy: Vaginal, Abdominal, or Radical Spine with implants Hernia with mesh Cardio−thoracic High Risk Genitourinary (ASA > 3) Abdomincal (Gastroduodenal, Biliary) Appendectomy (Uncomplicated) Vascular Colorectal

Note:

Use two methods of patient identification. Place this form in the Consent Section of the chart.

Developed 3/02 Rev 4/02 Rev 8/02 Rev 10/02 Rev 1/05 SHHS N−Rev 2/05 NSG00003

PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000

BLOCK TREATMENT RECORD Date:

Pre−Op Start:

End:

OR Room #:

OR Start:

End:

Surgeon:

MD Start:

End:

Circulator:

PACU Time:

Scrub:

Pre−Op Diagnosis:

XRay:

Surgical Procedure:

Medication Injection Charges 35516689 − IV Piggy/back/hr:

35516670 − IM or Sub Q Injection:

35516662 − IV Push Injection:

35516697 − Moderate Sedation:

Outpatient Surgery Implant & Equipment Verification Checklist / Logging / QA Time In:

Time Out:

Signature:

Case Set Up:

Finish:

Room Clean Up:

Surgeon Late: (LO2)

[ ] Case Scheduled for [ ] Case Bumped/Delayed until [ ] Case Moved to Main OR Comments

Case Delay

[ [ [ [

Difficult Intubation: (Q29) Equipment Malfunction: (C09) Case Cancelled Due to:

Patient Return to OR: (C23)

Finish:

[ ] Surgery arrived at: [ ] Called Charge Nurse to Notify [ ] Case Cancelled

Yes / No

] Lab−L08 [ ] Anesthesia − L03 [ ] Pt. Late Arrival − L01 [ ] Pre−Op − L12 [ ] Transport − L13 ] Line Placement [ ] Previous Case Ran Late − L07 [ ] Unavailable Equipment − C15 ] X−Ray − C−Arm − L09 [ ] X−Ray − Portable − L09 [ ] Unavailable Instruments ] Unavailable Staff [ ] Circulator − C19 [ ] Scrub − C18 [ ] Retractor − C17 Length of Delay: Comments:

[ ] Multiple Attempts [ ] Flexible Intubation Comments

[ ] Oral − Laryngeal Trauma [ ] Light Wand

[ ] Removed from Patient Care [ ] Report of Event Filed [ ] Describe Event:

[ ] Reported to Bio−Med for Repairs [ ] Name of Equipment:

[ ] Patient Condition − C03 [ ] Anesthesia − C02 [ ] Case Transferred to Main OR − C24 Comments [ ] Hemmorrhage Comments

[ ] Airway Control

[ ] Laryngospasm [ ] Case Cancelled

[ ] Surgeon − C04

[ ] Patient Request

[ ] Unstable Vital Signs

IF CASE CANCELLED WHILE PATIENT ON O.R. TABLE OR IF PATIENT RETURNS TO O.R. IN SAME DAY, YOU MUST FILL OUT REPORT OF EVENT FORM

************************************************************************************************************************* IMPLANT INFORMATION: APPLY STICKERS IF AVAILABLE Manufacturer:

Model #:

Size:

Catalog #:

UCG: [ ] Yes [ ] No

Lot #: Quantity: Dev: 10/2001 rev 6/05 OPS00006

r*NE109*r

PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000

NE1091 Discharge Instructions

Dear Patient:

You have just received an epidural steroid injection at Providence Hospital as requested by your referring physician. The medication placed by the anesthesiologist will require 24 to 48 hours to help alleviate your pain. You may feel discomfort at the site of the injection for a day or two. The anesthesiologist performing the procedure will be happy to explain the procedure and answer all questions. Your referring physician will manage your need for additional epidural injections, bed rest or physical therapy. Thank you for this opportunity to help relieve your pain. If you have questions or need further assistance after hours, you may call 633−1000 and ask to page anesthesia on call.

Anesthesia solutions Providence Hospital − Pain specialist Physicians

Dr. Braswell

Dr. Fontenot

Dr. Marchese

Dr. Archibald

Dr. Steinhauer

Dr. Foster Dr. Peattie

6801 Airport Blvd., P.O. Box 850429, Mobile, Alabama 36685 (251) 633−1000 block005

Anesthesia Solutions of Mobile Providence Hospital Pain Management Billing Record Attention: Green dotted areas created for VitalMed use.

Pain Mgmt Provider: ____________________________ Referring Physician: ____________________________ Date of Service: __________ Admit Status (Circle One): Outpatient (< 24 hr)

Inpatient

Diagnosis(es):

Office

ICD−9 ICD−9 ICD−9 ICD−9

Pain Management (See green Anesthesia billing record for post−op pain mgmt) Procedure(s): (Give Specifics)

CPT−Mod

CPT−Mod

CPT−Mod

CPT−Mod

CPT−Mod

CPT−Mod

Was anesthesia provided for this pain mgmt procedure?

Outpatient Eval and Mgmt (E&M) *New or Established Outpt Consult

Yes

No

If yes, fill in green anes. tickets for MDA/CRNA.

Outpt E&M cont. Established Outpt Office Visit (non−consult)

Initial Inpt Hosp Visit (not consult) 99221

Detailed

99241

Problem Focused

99211

Nurse visit

99222

Comprehensive

99242

Expanded Problem Focused

99212

99223

Complex

99232

99243 99244

Detailed

99213

Comprehensive

99214

Problem Focused Expanded Problem Focused Detailed

99245

Complex

99215

Comprehensive

New Outpt Office Visit (non−consult)

Inpatient Eval and Mgmt (E&M)

Subsequent Inpt Hosp Visit (not consult) 99231

99233

99201

Problem Focused

*New or Established Initial Inpt Notes: Consult

99202

Expanded Problem Focused

99251

Brief

99203

Detailed

99252

Intermediate

99204

Comprehensive

99253

Extended

99205

Complex

99254

Comprehensive

99255

Complex

Problem Focused Expanded Problem Focused Detailed

ANES0005

PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000

Anesthesia Record Date OR No. Surgeon(s) Anesthestist/Anesthesiologist

Lithotomy R Axillary roll Out Lubed Goggles Hot line

Surgery start Surgery end Anesthesia end

of

Name of Operation

INDUCTION

MONITORS & LINES

REGIONAL

❏ Pre−oxygenation ❏ Intravenous ❏ Inhalation ❏ Cricoid pressure ❏ Rapid sequence Antibiotic and time dosed:

❏ Anesthesia machine checked out ❏ Pulse oximeter ❏ EKG BP cuff: ❏ L ❏ R Stethoscope:❏ Esoph ❏ Precord ❏ Temp: ____________________________ ❏ Gas analyzer ❏ ET CO2 ❏ Nerve stimulator ❏ EEG ❏ A−Line: ___________________________ ❏ CVL: _____________________________ ❏ Swan: ___________________________ ❏ PIVs: ____________________________

❏ Spinal ❏ Epidural ❏ Ankle ❏ Interscalene ❏ Axillary ❏ Bier ❏ Other: _______________________________ Position: _______________________________ Needle gauge & type: ____________________ Level inserted: __________________________ ❏ Midline ❏ Paramedian Attempt x _______ ❏ Catheter ______ cm ❏ CSF ❏ Blood ❏ Paresthesia Level: _________________________________ Drugs & Doses

INTUBATION

TIMES Discontinuous time Start (if applicable) End Anesthesia start

OP1123

Page

POSITIONING ❏ Supine ❏ Prone ❏ ❏ Lateral: ❏ L ❏ ❏ Pressure point pads ❏ Arms: ❏ Tucked ❏ Eyes: ❏ Taped ❏ ❏ Pads ❏ ❏ Warming blanket ❏

r*OP123*r

❏ Oral ❏ Nasal ❏ Trach ❏ Direct ❏ Fiberoptic ❏ LMA ❏ Blade: _______________________ TOURNIQUET Tube: ___________________________ : _____________ ❏ Arm ❏ Leg Secured @ ______cm ❏ Cuff : _____________ ❏ L ❏ R ❏ ET CO2 ❏ BBS ❏ Teeth intact ❏ Stylette __________ mmHg Time: _____________ Block performed by (initials): _______________ ❏ Difficult ⇒ see remarks

Time: Oxygen(L/min) ❏ N2O ❏ Air TOTALS 1 2 3 4 5 6 7 8 9 10 11 12

(ET%) 1 2 3 4 5 6 7 8 9 10 11 12 EKG FiO2 SaO2 ET co2 Temp EBL Urine output Anesthesiologist in room (initials) 220

220

❏ Pt re−evaluated 200

200

immediately before anesthesia 180 induction

180

Induction

160

160

140

140

HR ∨ ∧

120

120

BP

100

100

80

80

60

60

40

40

20

20

Respiratory Rate 10

10

•

Emergence

Cont. available

Available for RR

Ventiliations ( S/A/V )

Tidal Volume

Peak Inspiratory Press

Remarks:

REV 10/02 ANES0001a

PRE−ANESTHESIA EVALUATION Height Vital Signs NPO after: Previous anesthesia/surgeries ❏ None ❏ No Problems ❏ Problems

Date: Diagnosis: Medications ❏ None

Allergies NKA

Weight

Family history of anesthesia No Problems ❏ Problems ❏

❏

HISTORY AIRWAY ❏ ❏ ❏ ❏

Loose teeth Caps/crowns Dentures Difficult intubation

❏ ❏ ❏ ❏

HTN PVD CAD/Angina Arrhytmias

❏ neck extension ❏ thyromental distance ❏ mouth opening

CARDIOVASCULAR ❏ ❏ ❏ ❏

TESTS & LABS (if blank, none needed)

COMMENTS Mallampati class: ❏ I ❏ II ❏ III ❏ IV ❏ No problems

CHF Pacemaker Previous MI Previous CABG

r*OP123*r RESPIRATORY

❏ No problems

❏ Asthma ❏ Smoker ❏ Emphysema/COPD ❏ Pneumonia/bronchitis ❏ Sleep apnea/CPAP

NEURO/MUSCULOSKELETAL

❏ Stroke/CVA ❏ TIA ❏ Dementia

❏ No problems

❏ Paralysis ❏ Seizures ❏ Neuromuscular dz

GI/LIVER

RENAL/ENDOCRINE

OTHER

CXR

❏ No acute disease

HCG

❏ NA ❏ Neg ❏ Pos

PT (INR) ❏ No problems

PTT

❏ Renal insufficiency ❏ CRF/dialysis

❏ Anemia ❏ Pregnancy ❏ Eye disorders

❏ NL

❏ No problems

❏ Nausea & vomiting ❏ Jaundice/hepatitis ❏ Bowel obstruction ❏ Hiatal hernia/reflux ❏ ETOH ❏ Obesity ❏ NIDDM ❏ IDDM ❏ Throid disease

EKG

Other ❏ No problems

❏ Bleeding disorder ❏ Sickle Cell ❏ Joint problems

Planned anesthetic/special monitors ❏ General ❏ A−line ❏ Spinal ❏ CVP ❏ Epidural ❏ Swan−Ganz ❏ Block ❏ MAC

❏ Risks, benefits, and alternatives of anesthetic plan discussed with patient/family.

Signature:

RECOVERY ROOM Admission time: BP P RR FiO2 Sat Temp

INS Crystalloid Colloid PRBC OUTS EBLUrine

Date:

Airway: ❏ None ❏ Oral ❏ Nasal ❏ Other:

ASA CLASS ❏ I ❏ II ❏ III ❏ IV ❏ V

❏ E

Time:

POST − ANESTHESIA DATA Sensorium: ❏ Awake Seen ❏ Reactive Cardiopulmonary status: ❏ Non−reactive Condition ❏ Satisfactory ❏ Guarded

❏ No Anesthesia Complication ❏ Comments if Complications:

Anesthetist: ___________________________________________________________

ANESTHESIA RECORD

OP1123 − Anesthesia

REV 10/02 ANES0001b

PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000

Anesthesia Solutions of Mobile, Inc. Consent for Anesthesia

r*CONSET*r

I hereby authorize and direct Anesthesia Solutions of Mobile, Inc. and the individual anesthesia provider to care for me, and to administer general, regional, or monitored anesthesia care (intravenoussedation) for surgery . The nature, purpose, and risks of the anesthetic, the possibility of complications, as well Anesthesia Solutions of Mobile as alternatives have been fully explained by ____________________________. I understand that although favorable results can be expected, they cannot be and are not guaranteed. It is the understanding of the undersigned that an Anesthesiologist, or a Certified Registered Nurse Anesthetist (CRNA) under the direction of the Anesthesiologist, will administer the anesthesia, andthat the administration and maintenance of anesthesia. is an independent function from the surgery

Signature of patient or guardian

Witness

Date

CONSENT consent

Developed July, 2002 Revised September, 2002 N4/03 CON00002

PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000

OPS MARS / IVARS

Date: INIT. / SIGNATURE / TITLE

INIT. / SIGNATURE / TITLE

OMISSION CODES R N U D I H O

PATIENT REFUSED NPO OFF UNIT DIALYSIS IV OUT HOLD PER ORDER OTHER−NURSES’ NOTES

INJECTION CODES LD RD LG RG LL RL LV RV LA RA

LT RT LT RT LT RT LT RT LT RT

PAIN SCALE

DELTOID DELTOID GLUTEUS GLUTEUS VASTUS LATERALIS VASTUS LATERALIS VENTRAGLUTEAL VENTRAGLUTEAL ABDOMEN ABDOMEN

0 NO PAIN

(0−10 SCALE)

10 UNBEARABLE PAIN

ALLERGIES:

TIME

ID COMMENTS TIME

ID COMMENTS TIME

ID COMMENTS

Lidocaine 1% .2ml − 1 ml prn ID IV Insertion

r*PM5013*r IV

1000 RL

KVO

Line One: [ ] Started [ ] Maintained Location/Size: Attempts X Site/Condition: [ ] Without redness/swelling * Requires Comment [ ] Flushes easily *Comments:

PM5013 − OPS MARS

[ ] D/C [ ] Restarted Tubing X INT X [ ] Dressing dry/intact [ ] Redness*

BY: Pump X [ ] Infiltrated* [ ] Left > 3 days (rationale)*

DAF X [ ] Bruised*

Dev: 10/01

Revised: 03/03 OPS00004

r*OP125*r

PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000

OP1125 − PACU Record

OUTPATIENT SURGERY PAIN MANAGEMENT IN

30

60

90

ASSESSMENT/REASSESSMENT

Pain Scale (0−10) (Document pain level above/and initials below)

Instructed to call for pain Pharmocological intervention (refer to MAR for details) Non−pharmacologic Interventions

Reposition Cold Application Heat Application Exercises Imagery Back rub Distraction Relaxation Other

Reassessment following intervention (Pain level above/and initials below) Monitored for possible side effects related to Meds (i.e. nausea, vomitting, constipation, itching, urinary retention, etc.)

Patient and/or family educated related to pain management plan.

OPS00005

PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000

PHYSICIAN’S ORDERS DATE HOUR

ANESTHESIA SOLUTIONS

STANDARD PRE BLOCK ORDERS 1. I.V. 1000cc LR @ KVO 2. May use Lidocaine 1% plain up to 1cc intradermal for IV insertion 3. UCG if needed 4. INR if taking Coumadin

r*PO104*r

_______________________________________ Signature Date

******************************************** POST BLOCK ORDERS

1. Discharge home

_________________________________________ Signature Date

Developed: January 2001 Reviewed: January 2002 Revised: October 2002

PO1004 − Physician Orders

BLOCK001

PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000

NURSING SURGICAL BLOCK / TREATMENT RECORD Date INTRAOPERATIVE RECORD OR #:

Preop Start:

End:

Surgeon:

OR Start:

End:

Circ:

MD Start:

End:

Scrub:

PACU Time:

XRay:

Preop Diagnosis: Surgical Procedure:

r*OP501*r

Prep:

INTRAOPERATIVE RECORD

Betadome (per physician)

Other:

C−Arm Exposure Time:

BandAid to Site

Tray:

Lot:

Vital Signs Every 5 Minutes: Time:

Exp:

O2 per cannula at

B/P:

LPM

HR:

Not Used SaO2:

Resp:

Circulator Notes:

Skin Condition:

Flushed

Pale

Rash

Diaphoretic

Unchanged

Other:

Level of awareness upon discharge from OR:

Alert & Cooperative

Sedated

Other

Report to PACU Nurse:

OP5015 − Nursing Surgical Block Record

Rev 5/02 rev 10/02 BLOCK002

r*OP5016*r

PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000

OUTPATIENT SURGERY PHYSICIAN SURGICAL BLOCK/TREATMENT RECORD

DATE: _________________________________ TIME: __________ REFERRING PHYSICIAN: ___________________________ ❒ New Consult ❒ Original anesthesia consult on chart and updated prn Date of last block (or N/A):________________________

ANESTHESIOLOGIST’S RECORD

PRE−PROCEDURE NOTE

Additional H&P Information

VS ❒ See nurses record Mental Status Heart

Lungs

❒ A & OX3

❒ S1S2, RRR ❒ CTAB

Comorbidities

❒ None

PROPOSED PROCEDURE: ❏ Risks vs benefits, potential complications, alternative options discussed INDICATION(S) FOR PROCEDURE: ❏ Pain 2° terminal illness ❏ Pain not controlled by other medication ❏ ______________________________________________ ❏ Pain of uncertain origin PROPOSED ANESTHESIA ❏ Local ❏ Sedation ❏ MAC Plan for anesthesia, risks and benefits discussed ❏ Yes ❏ N/A

POST PROCEDURE NOTE PROCEDURE PERFORMED: ❏ Epidural steriod injection level:_______ ❏ Steriod caudal catheter to __________ cm. ❏ Stellate R _____ L ______ ❏ Lumbar sympathetic ❏ Facet PATIENT POSITION: ❏ Sitting ❏ Right lateral

❏ Prone ❏ Supine

❏ Left Lateral

MEDICATIONS USED: ❏ _________________mg Depo−Medrol ❏ Fentanyl ____________mcG ❏ IV Sedation used __________________ ❏ Contrast ❏ ________________________________ ❏ ________________________________ ❏ ________________________________ Effect of injection (physician/patient subjective): __________________________________ __________________________________ __________________________________

❏ Blood Patch ❏ Occipital R____ L ______ ❏ Intercostal ❏ Trigger Point ❏ ______________________________________ PREP: ❏ Betadine ________________________________________ ❏ Other ___________________________________________ DIAGNOSIS:

❏ Patient tolerated procedure well ❏ Prescription given for: ____________________

Note Moderate sedation consisting of ___mcg of Fentanyl and ___mg of Versed was given in the operating room at my direction. A trained observer, a registered nurse, assisted in the monitoring of the patient’s level of consciousness and physiological status. The moderate sedation services included the assessment of patient, establishment of IV access, and fluids to maintain patency, administration of the anesthetic agent, maintenance of sedation, monitoring of oxygen saturation, heart rate, and blood pressure, and monitoring of patient in recovery.

Date Printed:

________________________________________________ BLOCK003 Anesthesiologist’s Signature Date/Time

PROVIDENCE HOSPITAL 6801 Airport Boulevard, Mobile AL 36608, 251/633−1000

OPS Pre−Op/PACU

Surgical Epidural Block/Treatment Record Date

Referring Physician:

Date of last Block (or N/A): Pre−Op Call: Pre−Op Nurse’s Record:

Time In: Pre−Block Vital Signs: Allergies: Weight: NPO (Yes)

(Time/Date)

Recent MRI/CT:

Where:

❏Alert ❏Oriented − Time, Place, Person ❏Ambulatory ❏Wheelchair ❏Stretcher Past Anesthesia Problems ❏Yes ❏No BP P R SAT Malignant Hyperthermia ❏Yes Height (No)

Patient History Yes Cardiovascular Pacemaker/ICD Last EKG Hypertension Pulmonary TB Bleeding Disorders Diabetes ENT Neurological Visual Disorder/ Glaucoma Kidney/Dialysis Urine−Other Thyroid Hepatitis/Liver HIV Musculoskeletal Cancer GYN/LMP Pregnant/Lactating Gastrointestinal Anxiety/Depression Mental Illness Abuse/Neglect Well Nourished

r*OP501*r

Post Block Record: Time In: Vital Signs: P Time: B/P P Time: B/P

Pain Level (0−10) ❏Patient Denies taking Coumadin

No

If yes, explain

Medicine:

Dose:

Where:

Nurse Notes:

RN Signature: Nurse Notes: R R

SAT SAT

DISCHARGE CHECK LIST YES NO N/A 1. Vital Signs stable within normal acceptable limits 2. Stable wound site, skin warm and dry 3. Ambulates without dizziness and with stable BP 4. Comfortable and free of excessive pain. PAIN LEVEL: 5. Alert, oriented to time, place and person.

OP5015 −NursingSugical Block Record

❏No

DISCHARGE CHECK LIST 6. Able to take PO fluids without nausea 7. Voided post−Op (Amt. ___________) 8. Verbal and written instructions given 9. Prescription given:

YES NO N/A

Accompanied by: Transportation per: Discharge Time: RN Discharging: Rev 5/02 rev 10/02 BLOCK004