Anaesthesia record
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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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Keeping

Anaesthesia record

KEEPING


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

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


  • Keeping

    ANAESTHESIA RECORD 1912, TOLEDO, OHIO


    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


    Comparison of automated and manual anesthesia record keeping

    Comparison of automated and manual anesthesia record keeping


    Comparision contd

    Comparision Contd.

    • Anesthesia task Manual anesthesia Automated

    • main categories records anesthesia records

    • 1. Recording anesthesia 21,9 % 12,9 %

    • 2. Direct patient care29,0 % 34,9 %

    • 3. Supplementary activities 29,4 % 30,1 %

    • 4. Watching surgery7,5 % 9,0 %

    • 5. Communication12,2 % 13,1 %

    • Total100 % 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”.


    Keeping

    Thank You


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