DOCUMENTATION CONTENTS IN CASE SHEET

1. Initial assessment

2. Medications in the right hand side of the case sheets. 3. Date, time, signature and name in where ever notes are made in the case sheets 4. Diagnostic list and results 5. Pre operative assessment report. Includes both surgical and anaesthesia 6. Surgical and anesthesia consent. Where surgeon and anesthetist also should sign. 7. Inter procedural monitoring for moderate sedation Heart rate Respiratory rate Blood pressure Oxygen saturation Level of sedation Anesthesia plans ( if any reevaluation is happening, hoth has to be documented.) 8. Inter procedural monitoring for anesthesia a. heart rate b. cardiac rhythm c. respiratory rate d. BP e. Oxygen saturation f. Airway security g. Potency and level of anesthesia 9. detailed surgical notes 10. post operative plan

11. content of discharge summary a. reason for admission b. significant findings and diagnosis c. information regarding investigation results d. any procedure performed e. medication and other treatment given f. follow up advice, medication and other information