5.20.3FCA_IISection
Administrative
lines 6063–6063id: 5.20.3
11 items
- 5.20.3.1FCA_IIClearly document clinical findings, assessment, and conclusions during patient evaluation.
- 5.20.3.2FCA_IIDocument multidisciplinary discussions and decisions around patient care choices including opposing views.
- 5.20.3.3FCA_IIAbility to acquire relevant legal documentation regarding advanced directives.
- 5.20.3.4FCA_IIAccurately document the pre-operative informed consent process, providing documentation of risks and benefits of proposed anaesthesia, procedures, or therapies
- 5.20.3.5FCA_IIEnsure clear documentation and communication of pre-medication prescriptions and instructions such as fasting orders for nursing staff, surgical colleagues, and patients.
- 5.20.3.6FCA_IIKeep contemporaneous anaesthetic records and document anaesthetic and other challenges including adverse medication reactions.
- 5.20.3.7FCA_IIDocument PACU monitoring and status at discharge.
- 5.20.3.8FCA_IIDocument handover to post-operative team and document appropriate therapies and targets.
- 5.20.3.9FCA_IIAccurately document complications and their management.
- 5.20.3.10FCA_IIDocument debriefing sessions and team discussions
- 5.20.3.11FCA_IIDocument full disclosures to patients of anaesthesia-related complications