Timing of Pre-Induction Assessments

Question:

We were cited by The Joint Commission during our last survey for our documentation process for immediate pre-induction assessment.  The finding was around timing of the assessment; however, the assessment is completed immediately before the procedure (but not documented until after).  What are your thoughts?

Answer:

This is a fairly easy standard to accomplish.  Part of the answer is getting providers to describe what they consider their “immediate pre-induction assessment.”  You state your policy indicates that it is the last set of vitals prior to induction. If the provider checks the monitor for the patient’s vitals, looks at the patient and sees everything is as it should be, and then starts the sedation, that is indeed the immediate pre-induction anesthesia assessment.  

Now, you just need to figure out documentation:

In a paper anesthesia record environment, you can have a space for the vitals and have the first column highlighted in grey or can have a special header that says “immediate pre-induction assessment” or something of the sort.  If the provider can speak to it, then you are covered.  You have vitals, the provider looked at the vitals and the patient, and then made the decision to continue with sedation.