Fourteen points need to be checked before you begin. The difficult part is rarely assessing them – it’s getting them written down while you still remember what you saw.

It’s 7:40 a.m. The first patient on the schedule is a 74-year-old who is scheduled to have a hip replacement. He is taking apixaban, and there is a previous note from 2014 about «difficult intubation» without further details. He is mostly wondering whether she will have time to call her daughter first. You do the check-up, you get the answer you need, you form an image. Then you move on to the next patient, and for now that image is just in your head.

The Preoperative assessment Norwegian is one of the places in the healthcare system where the distance between «evaluated» and «documented» is the shortest in time and the greatest in consequence. The evaluation is often done in a few minutes. The documentation of it must stand the test of time – for the next anesthesia, for the recovery, and for the rare day when someone reconstructs what was known in advance.

Fourteen points, and why they are written down

Norwegian standard for anesthesia (NSA), prepared by the Norwegian Anesthesia Society and the Anesthesiology Nurses NSF jointly, is effective from March 1, 2024. Chapter 4 lists what must be checked and assessed before initiation: planned procedure and planned anesthesia, physical and mental functional level, medical information including height and weight, current medication, allergies, bleeding history and coagulation status, response to additional examinations, results of any cardiac or pulmonary medical assessment, previous anesthesia experience, airway and intubation conditions with dental status and aspiration risk, pre-operative fasting, plan for perioperative follow-up – and ASA classification.

The standard also requires that frailty be assessed in patients aged 65 and older. This is a process that takes time to complete well, and one that is easy to leave aside in the notes because it has no numerical value to rely on.

NSA is formulated as a minimum standard. The Norwegian Anesthesiology Society describes it as normative guidelines for everyone who performs anesthesia work., Regardless of geography and organization. The standard also states something worth noting: deviations from the NSA must be justified and documented. This makes the documentation an integral part of the standard, not an appendage to it.

Who writes what – and why it isn’t obvious

Anesthesia is teamwork, and the documentation duty is individual. The National Board of Health is specific about exactly this in comments on the Health Personnel Act § 39The surgeon documents the reasons and prerequisites for the operation and what was performed, while the anesthesia nurse is responsible for recording what kind of anesthesia the patient received, the dosage, and how the patient reacted. Responsibility follows the person who made the observation.

The NSA states that supervision, preoperative information, and documentation are carried out by the anesthesiology nurse or LIS/specialist, while the LIS or specialist must clearly explain the patient and approve the anesthesia method before initiation. Two roles, two tracks in the same record. When things go wrong, it usually doesn’t go wrong in the assessment, but in the transfer between the tracks.

The Anesthesiology Journal is not alone either. The NSA requires that it be viewed in conjunction with the patient’s other records, and that there be a system for transferring information from the anesthesiology journal to the main record. That is where an observation about difficult airways either becomes a lasting information or remains a note in a form no one looks in for four years.

The regulation says the same, in other words

Patient record regulation § 4 requires that the record provides «an orderly and comprehensive presentation of the patient’s health condition so that it is easy for healthcare professionals to understand the patient’s health condition and, if necessary, any further planned healthcare». For a pre-operative assessment, this is almost a definition of the task.

Section 6 of the regulations explicitly mentions two things that anesthesia personnel recognize: Diagnostic considerations should be able to be seen, and critical information – including serious allergies and serious reactions to medications – should be there. The consideration is what separates «ASA 3» from «ASA 3 because…». The first is a code. The second is something that the next colleague can build on.

Section 7 adds a point that often gets lost in the rush: that advice and information are provided to the patient, and the main content of that information. The NSA states that the patient should be informed about relevant risk factors, and that the choice of premedication, the anaesthetic method, and, if possible, the postoperative treatment should be made in consultation with the patient. The conversation took place. The question is whether there is any record of it afterwards.

Where Medivox can take some of the burden

Medivox transcribes the clinical conversation into text and structures it according to templates you build. For pre-operative supervision, this means you can talk through the assessment while it’s fresh – at the bedside, in the hallway, or right after you leave the room – and get a draft that’s already sorted into the fields you actually use.

The point here is that you build your own templates. A pre-operative checkup at a local hospital with day surgery and a checkup before major open-heart surgery doesn’t need the same setup. The NSA is a minimum standard, not a template; how the minimum standard looks in your department is up to you. We have written more about what distinguishes a good journal entry from a complete one – a lot of that applies here as well.

All data is pseudonymized before it is further processed, and all data processing takes place in Norwegian data centers. You own the record and make the final assessment – Medivox documents the assessment you have already made and does not make any clinical decisions on your behalf.

The challenge of documenting under time pressure is not new, and it is not unique to anesthesia. The ambulance worker faces the same wall after a mission: the assessment was done correctly, but it was done while the hands were occupied with something else.

What will stand the test in four years

The Anesthesiology Journal is among the most structured documents in the Norwegian healthcare system. The NSA lists at least seventeen elements it should contain, from anesthesia equipment checks and airway assessments to documentation of problems and how they were handled. Much of this is captured automatically by the equipment.

What is not captured automatically is the rationale. Why you chose that airway strategy. What the patient told you about the previous anesthesia. Why you landed on ASA 3 and not 2. Those are the lines the next colleague is looking for – and those are the lines that are easiest to postpone until after the program, and therefore easiest to lose.

If you look back at last week: how many of your preoperative assessments could a colleague reconstruct from the record alone?

Frequently Asked Questions

Is the Norwegian standard for anesthesia legally binding? The NSA is normative guidelines developed by the professional community itself, not a regulation. It describes a minimum standard for proper anesthesia practice, and the standard requires that deviations from it be justified and documented.

Who has the documentation responsibility in anesthesia – the doctor or the nurse? Both, in their respective roles. The Directorate of Health specifies that the anaesthesia nurse is responsible for recording what kind of anesthesia the patient received, the dosage and the reaction, while the doctor documents his or her own assessments and decisions.

Should frailty be assessed in all elderly patients? The Norwegian standard for anesthesia recommends that frailty be assessed in patients aged 65 and older as part of the preoperative assessment.

Does speech-to-text work in an operating room? Dictation is the core function of Medivox, and it works best right after the assessment is done – at the bedside, in the preparation room, or on the way back. The text is structured according to the template you have created for your own supervision.

How long should the anesthesia record be able to be found again? The anesthesia record is part of the patient record and follows the same storage rules. NSA also requires that there be a system for transferring information from the anesthesia record to the patient’s main record.

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Do you work in an anesthesia department and are wondering what a pre-operative supervision might look like in a template? Contact us – we go through the setup together with you, with no commitment period.

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