Automated anaesthesia records

Abstract

Although the anaesthesia record was the normal method for keeping an account of the anaesthetist's interaction with the patient (Beecher, 1940), it was given a low priority in what has always been one of the more actionoriented medical specialties. For a long time, it was used as an aide-mOmoire for the anaesthetist. Today, the growing complexity of pharmacological interventions with the patient demand more sophisticated physiological monitoring, which has created the necessity for a legible, well-documented, complete and informative anaesthesia record. In recent times, there have been considerable advances in health-care delivery, especially in the postoperative period. This has made the anaesthetist's personal record even more important, as the record becomes 'common property' as a profile of the physiological state of the patient. This lays profound emphasis on the quality, clarity, accuracy and visual form of the presentation of the data in these records. If anaesthesia monitoring is compared to cockpit monitoring in an aircraft, the anaesthesia record can be considered as the black box--a vital source of information. This chapter presents an account of the purpose and clinical use of the automated anaesthesia record, its contribution to quality patient care, and the frequently debated issue of the merits and demerits of these records. To give an overview of a current automated anaesthesia recording system, we have provided a short technical description of an anaesthesia charting system developed in Erasmus University, which has been used in the Thorax Centre of the Academic Hospital, Rotterdam for more than ten years by every anaesthetist as an 'electronic secretary', taking down the minutes of the interaction between the anaesthetist and the patient.