The benefit of incorporating the anesthesia record
into the EMR for ARRA may be the most obvious benefit, but there are serious gains in patient safety that come from the automating record keeping.
A new, safety-oriented, integrated drug administration and automated anesthesia record
We found that the written anesthesia record
failed to record any vital signs for the final 30 minutes of the procedure.
They also find that most anesthesia groups have customized their paper anesthesia record
documentation to suit their needs.
The first problem with this manual system was that there was no guarantee that all appropriate results would be entered into the anesthesia record
With the Ultraview 2002 ADS, BIS information as well as other monitored vital signs values can be automatically integrated into a comprehensive anesthesia record
. This data forms the foundation for a comprehensive perioperative information management system.
W testified that he thought he gave 1 ml; the anesthesia record
indicated 2 ml; the hospital pharmacy record showed that a 5-ml ampoule was checked out for the case and that there were no wastage records to document disposal of any of these 5 ml.
Three types of self-reports completed by the primary anesthesia caregivers were examined: the anesthesia record
, the anesthesia quality assurance (AQA) report, and a posttrauma treatment questionnaire (PTQ).
Nurses were blind to the anesthetic technique used and had no access to the anesthesia record
. Patients were evaluated using a modified Aldrete score and modified Bromage score by the PACU nurse who made decision regarding the patient's eligibility to discharge to the Ambulatory Surgical Unit (ASU) for complete recovery before being discharged home.
Many now use automated record-keeping systems, which replace the old graphical anesthesia record
with a fully integrated digital printout that contains all the information you would normally expect in an anesthesia record
Typically, the manual anesthesia record
will record data every three or five minutes, and incomplete or missing anesthesia records
or surgical notes represent a potential litigation liability in the event of a negative outcome.
The anesthesia record
showed that the anesthesia monitoring machines recorded no vital signs for 20 minutes before caregivers began resuscitation.