dr venkatagiri k.m, m.d. pgdmle, pgdhhm,pgchm, pgchfwm consultant: anaesthesia, govt. gen....
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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
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MEDICAL RECORDMEDICAL RECORD
Clinical, Scientific, Administrative & Clinical, Scientific, Administrative & Legal document relating to patient Legal document relating to patient care on which is recorded sufficient care on which is recorded sufficient data written in sequence of events to data written in sequence of events to justify the diagnosis and warrant the justify the diagnosis and warrant the treatment & end resultstreatment & end results
(Mc Gibony)(Mc Gibony)
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HISTORY OF MEDICAL HISTORY OF MEDICAL RECORDSRECORDS
• 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
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Contd.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
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Medical Records in IndiaMedical 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
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ANAESTHESIA RECORDANAESTHESIA 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
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Need For Maintenance of Need For Maintenance of RecordRecord
• Part of Life.• Anaesthesia – Critical period
– Dynamic process.
Game of “passing the buck”.
• Conduct of Anaesthesia• Patient & Anaesthesiologist safety• Future conduct of Anaesthesia
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Contd.Contd.
Research & StudyResearch & Study StatisticsStatistics Medico legalMedico legal Courts take serious note of poor Courts take serious note of poor
recordrecord Require by lawRequire by law If you did it, you must record itIf you did it, you must record it Not recorded – not doneNot recorded – not done
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Types of Anaesthesia RecordTypes 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
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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
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Contd.Contd.
Consumes 15% - 20% of timeConsumes 15% - 20% of time Continuous watching / observing Continuous watching / observing
Patient & MonitorsPatient & Monitors
Record every drug / fluid & eventRecord every drug / fluid & event Record vitals every 5 min. – 15 Record vitals every 5 min. – 15
min.min. Cumbersome but write legiblyCumbersome but write legibly May not get timeMay not get time Patient care more importantPatient care more important
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ANAESTHESIA RECORD 1912, TOLEDO, OHIO
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AUDIT OF AUDIT OF ANAESTHESIA ANAESTHESIA RECORDRECORD 25%25% NO RECORDNO RECORD 45%45% INCOMPLETE OR INCOMPLETE OR
ILLEGIBLE IN ALL OR ILLEGIBLE IN ALL OR SOME SOME RESPECTRESPECT
30% 30% COMPLETE & COMPLETE & LEGIBLELEGIBLE
= 100%= 100%
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Computer Based Anae. RecordComputer 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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Contd.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
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Contd.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.
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Recent trendsRecent trends
• AARK used in more hospitals
• Connected to master server
• Real time transmission
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Comparison of automated and Comparison of automated and manual anesthesia record manual anesthesia record
keepingkeeping
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Comparision Contd.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 surgery7,5 % 9,0 % • 5. Communication 12,2 % 13,1 % • Total 100 % 100%
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FutureFuture
• 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
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PREOPERTIVE PREOPERTIVE INFORMATIONINFORMATION
• 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
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Contd.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
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Contd.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
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In OT / Induction roomIn 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
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In OT, before Sx CheckIn 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.
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Intra Operative RecordIntra 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
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Contd.Contd.
• Difficult - To Administer Anaesthesia. - Keep Watch on Patient. - Prepare Drugs. - Keep Record Simultaneously.
• If Record Keeping Delayed - -Facts Missed.
-Credibility Diluted.
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POSTOPERATIVE POSTOPERATIVE INSTRUCTIONSINSTRUCTIONS
• Drugs, fluids and doses
• Analgesic techniques
• Special airway instructions, incl. oxygen
• Monitoring
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SummarySummary
• 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
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Carry home messageCarry 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”.
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