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Anaesthesia record. KEEPING. Dr Venkatagiri K.M, M.D. PGDMLE, PGDHHM,PGCHM, PGCHFWM Consultant: Anaesthesia, Govt. Gen. Hosp.,Kasaragod Vice President, ISA Kerala. President, ISA Kasaragod City Branch. MEDICAL RECORD.

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Dr Venkatagiri K.M, M.D.

PGDMLE, PGDHHM,PGCHM, PGCHFWM

Consultant: Anaesthesia, Govt. Gen. Hosp.,Kasaragod

Vice President, ISA Kerala.

President, ISA Kasaragod City Branch

medical record
MEDICAL RECORD
  • Clinical, Scientific, Administrative & Legal document relating to patient care on which is recorded sufficient data written in sequence of events to justify the diagnosis and warrant the treatment & end results

(Mc Gibony)

history of medical records
HISTORY OF MEDICAL RECORDS
  • 2500 B.C.: Surgical Notes on Walls of Paleolithic caverns of Spain
  • 3000 B.C.: Sx Records in Egypt
  • 460 B.C. : Hippocrates Case reports of Patients in Greek
  • 160 A.D. Galen: Bedside records for Teaching
  • 865 – 925 Rhases : Medical records
contd
Contd.
  • 1137 St. Barthalomew’s Hosp. London
  • 1667 1st MRD at St. Barthalomew’s Hosp. London
  • 1752 Pennsylvania Hosp. in US Pt. Regstr
  • 1859 Massachusetts Gen. Hosp., Boston Medical Record Library
  • 1894 – 1st Anaesthesia Record
  • Dr. Franklin H. Martin & Dr. Malcolm H. Machan of ACS Improv in Qlt &Qnt of MR
medical records in india
Medical Records in India
  • 1946 Bhore Committee
  • 1962 Mudaliar Committee
  • 1959 – 1961 Dr. M.C. Gibony Director of Hosp. Admin. Prgm., Pittsburg Uni. Consultant to GoI, MoH. Orientn prgm. for Principals/ Deans & Spdt. of MC
  • Jain Committee & Rao Committee
  • MRD trng. JIPMER & CMC1962, Tvm MCH 1964
anaesthesia record
ANAESTHESIA RECORD
  • Part of Medical Record
  • Manual or Computer based
  • Started from time immemorial
  • Duty & responsibility of Anaesthesiologist
  • Legible, comprehensive, accurate & detailed
  • Pre op – intra op – post op
  • Describes events in a time scale
need for maintenance of record
Need For Maintenance of Record
  • Part of Life.
  • Anaesthesia – Critical period

– Dynamic process.

Game of “passing the buck”.

  • Conduct of Anaesthesia
  • Patient & Anaesthesiologist safety
  • Future conduct of Anaesthesia
contd1
Contd.
  • Research & Study
  • Statistics
  • Medico legal
  • Courts take serious note of poor record
  • Require by law
  • If you did it, you must record it
  • Not recorded – not done
types of anaesthesia record
Types of Anaesthesia Record
  • Manual
  • Computer based connected to HIMS
      • AAR- Automated Anaesthesia Record
      • AIMS- Anaesthetic Information Management System
      • EAR- Electronic Anaesthesia Record
      • CPRA- Computer Based Patient Record for Anaesthesia

Pre op to post op period

manual anaesthesia record
Manual Anaesthesia Record
  • Leaves to Paper
  • Observe, watch and write
  • Record as soon as you do
  • Delay will dilute / miss / forget crucial points – credibility lost
  • Adjust for convenience
  • Smoothening / Normalize
  • Spoilation
contd2
Contd.
  • Consumes 15% - 20% of time
  • Continuous watching / observing
          • Patient & Monitors
  • Record every drug / fluid & event
  • Record vitals every 5 min. – 15 min.
  • Cumbersome but write legibly
  • May not get time
  • Patient care more important
audit of anaesthesia record
AUDIT OF ANAESTHESIA RECORD
  • 25% NO RECORD
  • 45% INCOMPLETE OR ILLEGIBLE IN ALL OR SOME RESPECT
  • 30% COMPLETE & LEGIBLE
  • = 100%
computer based anae record
Computer Based Anae. Record
  • Robust real time second to second
  • Paperless Hospitals
  • Advanced countries
  • Saves time
  • Full details from Pre Op to Post Op
  • Online entries of drugs
  • Automated recording of monitor data
contd3
Contd.
  • More accurate
  • More details & more reliable
  • Easily retrievable
  • Connected to HIMS
  • Get access any where for any one
  • Cannot change / alter entries
  • Cannot normalize / smoothen
  • BUT Spoilation: Intentional distruction / mutilation/ concedment / alteration of evidence
contd4
Contd.
  • AIMS Handles Record of All Patients.
  • It can be used in ICU, PICU, Trauma Care Centres, Labour Room, Etc.
  • One can monitor many

Smooth transition to

      • Recovery room
      • Post op room
      • Ward
  • Needs knowledge of computer
  • Cumbersome clumsy keys

High Cost of Hardware, Software.

recent trends
Recent trends
  • AARK used in more hospitals
  • Connected to master server
  • Real time transmission
comparision contd
Comparision Contd.
  • Anesthesia task Manual anesthesia Automated
  • main categories records anesthesia records
  • 1. Recording anesthesia 21,9 % 12,9 %
  • 2. Direct patient care 29,0 % 34,9 %
  • 3. Supplementary activities 29,4 % 30,1 %
  • 4. Watching surgery 7,5 % 9,0 %
  • 5. Communication 12,2 % 13,1 %
  • Total 100 % 100%
future
Future
  • Bar Coded ETTs.
  • Bar Coded pre filled Syringes for different Medicines.
  • Bar Coded I.V. Fluids.
  • Specially Created Key Board
  • Special Pencil
  • Touch Screen
  • Speech Recognising Computer
preopertive information
PREOPERTIVE INFORMATION
  • Patient Identity
    • Name / I.D No. / gender
    • Demographic details
    • Date of birth / Age
  • Assessment and risk factors
    • Date of assessment
    • Assessor, where assessed
    • Weight (kg), [height (m) optional]
    • Basic vital signs (BP, HR)
    • Medication, incl. contraceptive drugs
    • Past History of Illness, Family History & Allergies
contd5
Contd.
  • Other problems
  • Addiction (alcohol, tobacco, drugs) & Habits
  • Experience of Previous Anaesthesia
  • Nature of Surgery
  • Examination of Patient
  • Potential airway problems
  • Prostheses, teeth, crown, contact lens
  • Examination of Patient
  • Investigations

as per Protocol

  • Cardio Respiratory fitness
    • As per protocol & sos
  • Optimise the Condition
  • Categorise ASA risk grading
contd6
Contd.
    • Informed Consent
      • Separate for Anaesthesia
      • Individualise
      • Highlight Specific Problems & discuss plans, pros & cons
      • Speak to Patient\'s Relative ASA Grading +/- comment
      • Signature / Witness
    • Plan for Anaesthesia Technique
    • Order Pre-medication
  • Urgency
    • Scheduled-listed on routine list
    • Urgent-resuscitated, not on a routine list
    • Emergency-not fully resuscitated
in ot induction room
In OT / Induction room
  • Checks
    • Nil by mouth
    • Consent
    • Premedication, type and effect
    • Drugs including blood & fluids, accessories like ETT, Ambu, Laryngoscope
  • Place and Time
    • Place
    • Date, start and end times
  • Personnel
    • All anaesthetists named
    • Operating surgeon
    • Qualified assistant present
    • Duty consultant informed
in ot before sx check
In OT, before Sx Check
  • Check the Anaesthesia Machine, Gas Connections, Airway and breathing system, Monitors – Record their proper working.
  • Sx planned
  • Vital signs recording/charting
  • Drugs and Fluids
  • Blood / Blood product availability
  • Patient position and attachments
  • Selection of Vein for I.V. Line – Record.
intra operative record
Intra Operative Record
  • Most Important & Most Difficult.
  • Record Position of Patient.
  • Record Vital Signs Every 5 Minutes.
  • Record Administration of Drugs.
  • I.V. Fluids, Blood & Blood products.
  • Record Batch No. Exp. Date & Manufacturer of all Drugs.
  • Mark Important Landmarks of Surgery
contd7
Contd.
  • Difficult

- To Administer Anaesthesia.

- Keep Watch on Patient.

- Prepare Drugs.

- Keep Record Simultaneously.

  • If Record Keeping Delayed -

-Facts Missed.

-Credibility Diluted.

postoperative instructions
POSTOPERATIVE INSTRUCTIONS
  • Drugs, fluids and doses
  • Analgesic techniques
  • Special airway instructions, incl. oxygen
  • Monitoring
summary
Summary
  • Duty bound to care & record
  • Pre op – intra op – post op
  • Recording is mandatory
  • Not recorded = not done
  • Delay will miss & cost you & your pt. more
  • Till AAR come do manual recording
carry home message
Carry home message
  • Keeping records is must.
  • If you did it, write it down.
  • If you don’t write it down, it didn’t happen.
  • Courts believe more in what you have written than what you Say.
  • Keep Records for all the Cases.
  • Only Detailed Record for case under consideration = “Fabrication of Evidence”.
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