PS06 2019: Anaesthesia record

 

List:

·         General comments

·         Secondary functions

·         Digital records

·         Basic information

·         Pre-op consult

·         Intra-op care

·         Post-op care

 

General comments:

·         Should be available for review during current and subsequent admissions

·         Should be provided to the patient and to other facilities upon request

·         Handwritten records should be legible

 

Secondary functions of the anaesthesia record:

·         Management of future care

·         Education

·         Research

·         Medico-legal

·         Departmental administration

·         Coding

·         Quality assurance

 

Regarding digital records:

·         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

 

Section 1: Basic information:

·         Patient details: name, DOB, MRN, sex, age, weight, height

·         Staff details: surgeon and anaesthetist

·         Location

 

Section 2: Pre-op consult:

·         ASA

·         History: HOPC, PMHx, anaes/surg Hx, meds, allergies, fasting status

·         Examination: observations, airway/teeth, resp, cardiovascular

·         Investigations: ECG, blood tests, imaging

·         Pre-medication

·         Plan, discussion, risks, consent (specific: students, photo, intimate exam)

 

Section 3: Intra-op care:

·         Date and time: observations at least 10 minutely (I am told?)

·         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

 

Section 4: Post-op care: (never seen most of this!)

·         ABC and neuro status prior to transfer from theatre

·         Any incidents during transfer

·         Plan for oxygen, fluid, analgesics, antiemetics

·         Post-anaesthesia visits

 

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