Documentation

The purpose of documentation is to preserve a permanent and accurate record of the care a patient receives. This includes documentation in the patient’s Personal Health Records (PHR), as well as equipment maintenance records, transfer of accountability (TOA) reports, adverse event/critical incident reports, etc. RTs working as AAs may document in a paper record, in an electronic system, or a combination, as specified by the facility where the patient care is provided. In addition, each phase of the continuum of anesthesia care (pre-operative, intra-operative and post-operative) has its own unique documentation requirements. However, RTs working as Anesthesia Assistants are required to adhere to the same documentation standards as RTs in any other practice setting and are responsible for documenting their own actions.  Note: It is not acceptable to allow another healthcare provider to record or document for the AA/RRT.

More information on the CRTO’s Documentation Standards can be found in the CRTO’s Documentation PPG and CRTO’s Standards of Practice – Standard 7.