The electronic pre-anesthesia form: An integral component of a new anesthesia information management system

Abstract

g g o l w early a decade ago, we set out to establish an anesthesia information management system AIMS) for our hospital. Anesthesia information anagement systems are a form of clinical inforation system (CIS) that is designed to manage linical information pertaining to the patient’s periperative experience. Such systems vary in their cope and features, but we saw little added value in cquiring a discrete, automated anesthesia record eeper. Instead, we sought out a comprehensive ystem that would record, process, and manage the ntire perioperative process. An important compoent of the perioperative CIS is the Pre-Anesthesia valuation Form, hereafter referred to as the aneshesia “preoperative form” or “preop” for short. his article describes our experience in developing nd implementing an electronic “preop” form for n anesthesia CIS. Traditionally, the anesthesia preoperative asessment has differed from the ubiquitous history nd physical used by other specialties. The form ontains a variety of information, including demoraphic information, surgical diagnosis, procedure, edications, allergies, past surgical history, exanded review of systems, abbreviated physical xam, listing of labs and tests, overall assessment, nd anesthetic plan. The electronic preoperative form embodies ore than a simple electronic record of a patient’s reoperative condition. The electronic form is the ynch pin for an electronic system that manages the erioperative workflow process. Information enered in the form is the basis of the manual and utomated decision-making processes and largely etermines the management of the patient’s aneshetic care. Theoretically, the computer could proess information contained in the form and use redetermined rules and algorithms to suggest any aspects of the patient’s perioperative care “rules-based logic”). An electronic form has numerous advantages ver its paper cousin, but these advantages may be ifficult to exploit and costly to develop. Furtherore, the benefits of an electronic system may be