This document discusses the history and importance of medical records, particularly anesthesia records. It notes that medical records have existed for thousands of years, becoming more standardized over time. Maintaining thorough and accurate anesthesia records is important for patient safety, medico-legal purposes, research, and demonstrating the quality of care provided. The document compares manual and computer-based methods of record keeping and outlines the key information that should be included in pre-operative, intra-operative, and post-operative anesthesia records.

2. 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
• 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

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

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

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

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

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 % 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.
– 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

40. 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

41. 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

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
- 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”.