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
 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
• 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.
• 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
• 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
• 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
• Part of Life.
• Anaesthesia – Critical period
– Dynamic process.

Game of “passing the

buck”.
• Conduct of Anaesthesia
• Patient & Anaesthesiologist safety
• Future conduct of Anaesthesia
 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
• 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
• 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
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
ANAESTHESIA RECORD 1912, TOLEDO, OHIO
AUDIT OF
ANAESTHESIA
RECORD
 25% NO RECORD
 45% INCOMPLETE OR
ILLEGIBLE IN ALL OR
SOME RESPECT
 30% COMPLETE &
LEGIBLE
= 100%
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
 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
 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

• AARK used in more hospitals

• Connected to master server
• Real time transmission
Comparison of automated and
manual anesthesia record
keeping
 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%
 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
• 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
 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
 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
• 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
• 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
• 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
 Contd.
• Difficult
- To Administer Anaesthesia.
- Keep Watch on Patient.
- Prepare Drugs.
- Keep Record Simultaneously.
• If Record Keeping Delayed -
-Facts Missed.
-Credibility Diluted.
 POSTOPERATIVE
INSTRUCTIONS
• Drugs, fluids and doses
• Analgesic techniques
• Special airway instructions, incl. oxygen
• Monitoring
 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
• 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”.