Professional Practice, Communication, and Documentation
The record is the care
Expectations converge from law, accreditation, and payer rules: a pre-anesthesia evaluation documented before induction, an intraoperative record updated at least every five minutes (vitals, agents, events, interventions), a post-anesthesia note, and complete medication entries with dose, route, time, and administrator. Late entries are labeled as late with the actual time written - never back-dated. Errors are corrected with a single line through the entry, the correction, initials, and date; nothing is obliterated or covered. "If it isn't documented, it didn't happen" is an accurate description of how records are read after an adverse event.
Communication that closes loops
SBAR structures reports. Closed-loop confirmation means the receiver repeats back the order - essential for drug doses and blood products. Standardized handoffs occur at shift change and at PACU transfer. When a concern is not addressed, use the defined chain of command rather than going silent.
Scope and ethics
Know the technician's boundaries: setup, equipment troubleshooting, positioning assistance, blood product handling, point-of-care testing, and supply readiness, while clinical decisions stay with the anesthesia professional. Witnessing a consent signature is not the same as obtaining informed consent. Protect privacy, be honest about errors, and never chart another person's entry as your own.
Rule of thumb: document what you observed and did, in objective terms, with times - not your conclusions.
Trap: pre-charting care before it happens, and charting a colleague's entry as your own.