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Anaesthesia record KEEPING.

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Presentation on theme: "Anaesthesia record KEEPING."— Presentation transcript:

1 Anaesthesia record KEEPING

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

3 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)

4 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

5 Contd. 1137 St. Barthalomew’s Hosp. London
st 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

6 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

7 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

8 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

9 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

10 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

11 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

12 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

13 ANAESTHESIA RECORD 1912, TOLEDO, OHIO

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17 AUDIT OF ANAESTHESIA RECORD
25% NO RECORD 45% INCOMPLETE OR ILLEGIBLE IN ALL OR SOME RESPECT 30% COMPLETE & LEGIBLE = 100%

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19 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

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21 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

22 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.

23 Recent trends AARK used in more hospitals Connected to master server
Real time transmission

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35 Comparison of automated and manual anesthesia record keeping

36 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%

37 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

38 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

39 Contd. as per Protocol Investigations Cardio Respiratory fitness
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 Investigations as per Protocol Cardio Respiratory fitness As per protocol & sos Optimise the Condition Categorise ASA risk grading

40 Contd. Informed Consent Plan for Anaesthesia Technique
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

41 In OT / Induction room Checks Place and Time Personnel
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

42 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.

43 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

44 Contd. Difficult If Record Keeping Delayed - -Facts Missed.
- To Administer Anaesthesia. - Keep Watch on Patient. - Prepare Drugs. - Keep Record Simultaneously. If Record Keeping Delayed - -Facts Missed. -Credibility Diluted.

45 POSTOPERATIVE INSTRUCTIONS
Drugs, fluids and doses Analgesic techniques Special airway instructions, incl. oxygen Monitoring

46 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

47 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”.

48 Thank You


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