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KEEPING

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

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  1. Anaesthesia record KEEPING

  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

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

  15. 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

  16. 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

  17. 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.

  18. Recent trends • AARK used in more hospitals • Connected to master server • Real time transmission

  19. Comparison of automated and manual anesthesia record keeping

  20. 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%

  21. 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

  22. 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

  23. 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

  24. 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

  25. 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

  26. 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.

  27. 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

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

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

  30. 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

  31. 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”.

  32. Thank You

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