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 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)

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

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

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

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

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

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

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

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.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

ANAESTHESIA RECORD 1912, TOLEDO, OHIO

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%

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

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

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.

Recent trendsRecent trends

• AARK used in more hospitals

• Connected to master server

• Real time transmission

Comparison of automated and Comparison of automated and manual anesthesia record manual anesthesia record

keepingkeeping

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%

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

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

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

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

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

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.

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

Contd.Contd.

• Difficult - To Administer Anaesthesia. - Keep Watch on Patient. - Prepare Drugs. - Keep Record Simultaneously.

• If Record Keeping Delayed - -Facts Missed.

-Credibility Diluted.

POSTOPERATIVE POSTOPERATIVE INSTRUCTIONSINSTRUCTIONS

• Drugs, fluids and doses

• Analgesic techniques

• Special airway instructions, incl. oxygen

• Monitoring

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

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”.