RECALL—an integrated system for making, retrieving and analysing anaesthetic records

Abstract

Summary This chapter describes a computerized system that has been designed to increase the accuracy, accessibility and utility of anaesthesia records. The software has been designed to provide flexible and easy data entry by anaesthetists. The extensive use of personalized menus allows rapid entry of intraoperative comments and noting of drug administrations. A chronological summary is instantly available whenever required. Drug data include time, dose, elapsed time since the previous dose and cumulative dose. All comments are automatically time and date stamped, and where appropriate, entries are checked to ensure that they lie within a legitimate range. To provide maximum flexibility, hand-held computers can be used for data collection on the ward as well as in the theatre. The system features direct interfacing of patient monitors which allows sampling at much faster rates than is possible using manual methods. A unique modular interface provides the flexibility to use a wide range of monitors of different makes and types. There is a full-colour, real-time trend graph of vital signs in a familiar format, and other screens may be selected without interrupting the acquisition of data in real time. Printed anaesthetic records are available both during and after the operation. The standard file copy for general use is in A4 format and contains all important data presented in chronological order. It is possible to obtain more detailed output for specialized needs. All data are stored in an electronic database from which records can be retrieved within seconds whenever required. Internal coding makes use of the Read Clinical Classification enabling meaningful exchange of data with other systems. Individual work stations are intended to be linked in a local area network which allows access to the shared database from any work station. There is also the potential for direct communication with the hospital patient administration system (PAS). The system produces a number of routine reports relevant to departmental activity analysis and analysis of resource usage. The database is interfaced to statistics software which gives access to a wide range of powerful techniques in addition to providing presentation-quality tables and graphs. In summary, the RECALL system is designed to automate the task of anaesthetic record-keeping so far as this is practicable and to free the anaesthetist's time for patient-oriented activities. It incorporates many features of practical importance and has proved a useful contribution towards improved standards of patient care. It makes it easy to prepare and retrieve anaesthetic records and its capability to analyse recorded data offers valuable aid in medical audit and theatre administration.