PS06 The Anaesthesia Record. Recommendations on the Recording of an Episode of Anaesthesia Care

Abstract

From Introduction: The anaesthesia record is an essential part of the patient's medical record. The record should allow the anaesthetist to document all aspects of the anaesthesia management, including the pre and post-operative management, that are of relevance to the anaesthesia. The anaesthesia record provides information that may assist other staff involved in the care of the patient and to any subsequent anaesthetists. It may also be of medico-legal importance and can be used for quality assurance and research purposes. The record must be signed by the anaesthetist/s. The information may be on a single record or may be covered by separate records for the pre-anaesthesia, anaesthesia and postanaesthesia phases of the patient’s care. All components of the anaesthesia record must be readily available throughout a patient’s hospital stay, and for all subsequent attendances