In the U.S., anesthesia record laws vary state-to-state. In the state of Texas, for example, the law requires specifically that you have to have a separate sedation/anesthesia checklist page with very specific items listed on it.
Even if we have all the items already in the Anesthesia Record that Xchart produces, the law specifically denotes that the checklist needs to be a separate page.
If you're curious, you can read the Texas law for yourself in the Texas Administrative Code.
Similar requirements exist in other states for various types of providers.
As of today, you can now optionally generate a separate page along with your anesthesia/sedation record using Xchart:
The page is still somewhat flexible:
- Everything on the "Other Pre-operative Checks" is customizable. This is just your pre-operative checklist which can be edited in the app.
- The "Additional Pre-Anesthesia Risk Assessment Notes" is just the notes section on the "Physical" page.
- We added a question for "Medical Consult" as part of this release in part because Texas specifically mentions it, but also because it's something we've been wanting to do regardless.
- Texas only requires a checkmark for "Health History reviewed". If you, on the "Systems Review" page specify "previously reviewed with patient" then that is the phrase that will be inserted into the preoperative checklist. If you complete the systems review, we'll add all the details as shown in the screenshot above.
Beware that Texas specifically asks for:
"Special preoperative considerations as indicated for sedation/anesthesia administered to pediatric or high risk patients."
"The preoperative checklist must include documentation of the reason for omission of any items required by subsection (c) of this section."
So be sure to use the "Additional Pre-Anesthesia Risk Assessment Notes" section to note anything relevant.
Obviously, this is not legal advice and it's up to you to ensure the documentation you produce is in accordance with applicable laws.
But, we hope that this is a helpful feature, especially for those of you required to produce a document like this.
If you have feedback or other ideas for us please don't hesitate to reach out.
We always love to hear from our awesome customers: mailto:firstname.lastname@example.org.