2Consultant: Anaesthesia, Govt. Gen. Hosp.,Kasaragod Dr Venkatagiri K.M, M.D.PGDMLE, PGDHHM,PGCHM, PGCHFWMConsultant: Anaesthesia, Govt. Gen. Hosp.,KasaragodVice President, ISA Kerala.President, ISA Kasaragod City Branch
3MEDICAL RECORDClinical, 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)
4HISTORY OF MEDICAL RECORDS 2500 B.C.: Surgical Notes on Walls of Paleolithic caverns of Spain3000 B.C.: Sx Records in Egypt460 B.C. : Hippocrates Case reports of Patients in Greek160 A.D. Galen: Bedside records for Teaching865 – 925 Rhases : Medical records
5Contd. 1137 St. Barthalomew’s Hosp. London st MRD at St. Barthalomew’s Hosp. London1752 Pennsylvania Hosp. in US Pt. Regstr1859 Massachusetts Gen. Hosp., Boston Medical Record Library1894 – 1st Anaesthesia RecordDr. Franklin H. Martin & Dr. Malcolm H. Machan of ACS Improv in Qlt &Qnt of MR
6Medical Records in India 1946 Bhore Committee1962 Mudaliar Committee1959 – 1961 Dr. M.C. Gibony Director of Hosp. Admin. Prgm., Pittsburg Uni. Consultant to GoI, MoH. Orientn prgm. for Principals/ Deans & Spdt. of MCJain Committee & Rao CommitteeMRD trng. JIPMER & CMC1962, Tvm MCH 1964
7ANAESTHESIA RECORD Part of Medical Record Manual or Computer based Started from time immemorialDuty & responsibility of AnaesthesiologistLegible, comprehensive, accurate & detailedPre op – intra op – post opDescribes events in a time scale
8Need For Maintenance of Record Part of Life.Anaesthesia – Critical period– Dynamic process.Game of “passing the buck”.Conduct of AnaesthesiaPatient & Anaesthesiologist safetyFuture conduct of Anaesthesia
9Contd. Research & Study Statistics Medico legal Courts take serious note of poor recordRequire by lawIf you did it, you must record itNot recorded – not done
10Types of Anaesthesia Record ManualComputer based connected to HIMSAAR- Automated Anaesthesia RecordAIMS- Anaesthetic Information Management SystemEAR- Electronic Anaesthesia RecordCPRA- Computer Based Patient Record for AnaesthesiaPre op to post op period
11Manual Anaesthesia Record Leaves to PaperObserve, watch and writeRecord as soon as you doDelay will dilute / miss / forget crucial points – credibility lostAdjust for convenienceSmoothening / NormalizeSpoilation
12Contd. Consumes 15% - 20% of time Continuous watching / observing Patient & MonitorsRecord every drug / fluid & eventRecord vitals every 5 min. – 15 min.Cumbersome but write legiblyMay not get timePatient care more important
19Computer Based Anae. Record Robust real time second to secondPaperless HospitalsAdvanced countriesSaves timeFull details from Pre Op to Post OpOnline entries of drugsAutomated recording of monitor data
21Contd. More accurate More details & more reliable Easily retrievable Connected to HIMSGet access any where for any oneCannot change / alter entriesCannot normalize / smoothenBUT Spoilation: Intentional distruction / mutilation/ concedment / alteration of evidence
22Contd. AIMS Handles Record of All Patients. It can be used in ICU, PICU, Trauma Care Centres, Labour Room, Etc.One can monitor manySmooth transition toRecovery roomPost op roomWardNeeds knowledge of computerCumbersome clumsy keysHigh Cost of Hardware, Software.
23Recent trends AARK used in more hospitals Connected to master server Real time transmission
35Comparison of automated and manual anesthesia record keeping
36Comparision Contd. Anesthesia task Manual anesthesia Automated main categories records anesthesia records1. 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%
37FutureBar Coded ETTs.Bar Coded pre filled Syringes for different Medicines.Bar Coded I.V. Fluids.Specially Created Key BoardSpecial PencilTouch ScreenSpeech Recognising Computer
38PREOPERTIVE INFORMATION Patient IdentityName / I.D No. / genderDemographic detailsDate of birth / AgeAssessment and risk factorsDate of assessmentAssessor, where assessedWeight (kg), [height (m) optional]Basic vital signs (BP, HR)Medication, incl. contraceptive drugsPast History of Illness, Family History & Allergies
39Contd. as per Protocol Investigations Cardio Respiratory fitness Other problemsAddiction (alcohol, tobacco, drugs) & HabitsExperience of Previous AnaesthesiaNature of SurgeryExamination of PatientPotential airway problemsProstheses, teeth, crown, contact lensInvestigationsas per ProtocolCardio Respiratory fitnessAs per protocol & sosOptimise the ConditionCategorise ASA risk grading
40Contd. Informed Consent Plan for Anaesthesia Technique Separate for AnaesthesiaIndividualiseHighlight Specific Problems & discuss plans, pros & consSpeak to Patient's Relative ASA Grading +/- commentSignature / WitnessPlan for Anaesthesia TechniqueOrder Pre-medicationUrgencyScheduled-listed on routine listUrgent-resuscitated, not on a routine listEmergency-not fully resuscitated
41In OT / Induction room Checks Place and Time Personnel Nil by mouthConsentPremedication, type and effectDrugs including blood & fluids, accessories like ETT, Ambu, LaryngoscopePlace and TimePlaceDate, start and end timesPersonnelAll anaesthetists namedOperating surgeonQualified assistant presentDuty consultant informed
42In OT, before Sx CheckCheck the Anaesthesia Machine, Gas Connections, Airway and breathing system, Monitors – Record their proper working.Sx plannedVital signs recording/chartingDrugs and FluidsBlood / Blood product availabilityPatient position and attachmentsSelection of Vein for I.V. Line – Record.
43Intra 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
44Contd. 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.
46Summary Duty bound to care & record Pre op – intra op – post op Recording is mandatoryNot recorded = not doneDelay will miss & cost you & your pt. moreTill AAR come do manual recording
47Carry 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”.