PS06 2019: Anaesthesia record

List:

· Contents

· Secondary functions

· Digital records

Basic info	· Patient details: name, DOB, MRN, sex, age, weight, height · Staff details: surgeon and anaesthetist · Location · Operation
Pre-op	· History: HOPC, PMHx · Examination: vital signs, ABC · Investigations: blood tests, cardiac, imaging · Plan: discussion, risks, consent (specific consent: students, photos, intimate exam)
Intra-op	· Date and time · Observations q10mins at least · Mode: general / neuraxial / sedation / local · Airway: type, size, problems · Breathing: circuit, mech vs spont, gases · Vascular access: type, size, location · Monitoring · Medications: dose, route, time, adverse effects · Fluid in: type, volume, time · Fluid out: urine output, blood loss · Position and pressure care · Complications or problems · Investigations: including blood gas
Post-op	· Plan for oxygen, fluid, analgesic, anti-emetic · Post-anaesthesia visits · Status prior to transfer · Incidents during transfer

· Management of future care

· Education

· Research

· Medico-legal

· Departmental administration

· Coding

· Quality assurance

· Anaesthetists should be involved in design

· Information should be classed either mandatory, highly desirable or optional

· Must allow electronic signature

· Should synchronise with workflow

· Should improve record keeping

· Should enhance vigilance and patient safety

· Should assistant the anaesthetist in making decisions

· Should not interfere with care

· Should be accessible for later review

· Should facilitate data collection