Anaesthetic Record

The anaesthetic record:

• Should be available:
  • Throughout hospital stay
  • On subsequent stays
• Should contain:
  • Basic details
    • Surgeon
    • Anaesthetist
    • Procedure
  • Basic patient information:
    • Name
    • Hospital number
    • Age
    • Gender
    • Weight
  • Pre-anaesthetic consult
    • Medical status
    • Medication therapy
    • Anaesthetic an surgical history
    • Airway assessment
    • Relevant investigations
    • Premedications
  • Anaesthetic information
    • Technique
    • Medication given
    • Airway used
      Description of problems encountered and solution.
    • Anaesthetic gas, flow, and ventilation use
    • Monitoring used
    • Vascular access
    • Fluid therapy
    • Blood loss
    • Patient Position
    • Timing of key events
  • Post-Anaesthetic Information
    • Respiratory, CVS, and neurological status
    • Time from discharge from operating theatre ore recovery room

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References

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