Documentation on the anesthetic record: correlation with clinically important variables

Tessler, Michael J.; Tsiodras, Athanasios; Kardash, Kenneth J.; Shrier, Ian

doi:10.1007/bf03022875

Cited by 11 publications

(4 citation statements)

References 10 publications

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“…12 In addition, reporting a difficult airway is always a subjective issue, making it difficult to follow-up and prepare for a subsequent intubation, especially when a patient is then treated in another hospital and by another anaesthesiologist. 13 In some institutions, after operation, information is communicated to patients concerning their difficult airway management, either verbally or in written form. Half of these patients informed verbally forget their notification.…”

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confidence: 99%

Videolaryngoscopy as a new standard of care

Zaouter

Calderon

Hemmerling

2015

British Journal of Anaesthesia

158

108

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Spinal hypotension is common in women who receive spinal anaesthesia for Caesarean delivery, with an incidence of up to 71%. 1 Spinal hypotension can occur precipitously and, if severe, can result in important perinatal adverse outcomes, such as maternal nausea and vomiting, fetal acidosis and may be an important contributory factor for maternal death related to regional anaesthesia. 2 3 Mothers with pre-delivery hypovolaemia may be at risk of cardiovascular collapse because the sympathetic blockade may severely decrease venous return. As a consequence, prevention of spinal hypotension has been a key research area within the field of obstetric anaesthesia. To prevent spinal hypotension, a number of approaches have been investigated, notably fluid loading, vasopressors, Editorials BJA

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confidence: 99%

Videolaryngoscopy as a new standard of care

Zaouter

Calderon

Hemmerling

2015

British Journal of Anaesthesia

158

108

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“…There were missing data for ASA physical status and emergency category. In the logistic regression model, only the cohort of subjects with complete data in all variables was considered . We used multiple imputations to assess the sensitivity of results to missing values .…”

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confidence: 99%

The association of time of emergency surgery – day, evening or night – with postoperative 30‐day hospital mortality

et al. 2018

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It is unclear whether the time of day for emergency surgery is associated with postoperative mortality. We assessed this association in 9319 patients who had emergency surgery as their first surgery at the Jewish General Hospital, Montreal, QC, Canada from April 2010 to March 2015. Of the 7362 (80%) patients with complete data, 168 (2.3%) died within 30 postoperative days. There was no significant association of time of day with postoperative mortality, with adjusted OR (95%CI) of 1.61 (0.96-2.72) for night vs. day, p = 0.07; 1.29 (0.78-2.13) for night vs. evening, p = 0.33; and 1.26 (0.89-1.78) for evening vs. day, p = 0.20. Studies of more patients and more factors, with longer follow-up, should be carried out to exclude important associations of time of emergency surgery with postoperative mortality and morbidity.

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“…Tessler surveyed the opinions of anesthesiologists to determine the variables they felt to be most important to document on the anesthetic record [35]. His subsequent chart review found that many of the variables considered important were infrequently recorded.…”

Section: Quality and Accuracy Of Contentmentioning

confidence: 99%

The Anesthetic Record: How Content and Design Influence Function In Anesthetic Practice and Beyond

Raymer¹

2011

J Anesth Clin Res

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IntroductionThe original anesthetic record was developed during the early days of the practice of Anesthesia to record pulse, as part of an effort to improve outcomes which at the time were poor. Though many aspects of our modern anesthesia practice would be unrecognizable to the pioneers of our specialty, the current handwritten anesthesia record looks remarkably similar to the original charts produced over a century ago [1]. Despite the superficial similarities, today's anesthetic record serves myriad functions beyond its central role as a medical record of anesthetic care. It is a key interdisciplinary communication tool, a source of information for research and quality assurance projects and a legal document that can be used in a wide range of medico-legal proceedings. The evolution of the record from handwritten to electronic form has advanced these roles, while at the same time bringing forth new challenges.The anesthetic record should promote the user's ability to achieve specific goals. Although it is an essential tool used by the Anesthesiologist on a daily basis, there is relatively little literature to guide its design and use. This article will describe the history of the anesthetic record and outline its use in our practice today. The content requirements, driven by legislative, medico-legal, professional and clinical factors, will be summarized. Finally, the impact of formatting choices, including handwritten and electronic media, is discussed. History and TerminologyThe first anesthetic records were devised in 1894 by two medical students, Harvey Cushing and Amory Codman. Often charged with delivering anesthetics for their surgical supervisor, Dr. F.B. Harrington, their descriptions of the use of those first charts offers a glimpse into the harrowing early days of the practice of Anesthesiology [1]. Cushing credits the charts with formalizing what had been, to that point "the very casual administration of a dangerous drug" [1]. His writings reveal how the recording of vital signs (pulse, respiratory rate, and later, blood pressure) along with the amount of ether administered was key in developing the understanding of cause and effect that modern-day anesthesiologists take for granted. The formative role that the anesthetic record played in both patient safety and the development of the specialty itself was noted by several observers, including Harold Griffith [2].The amount of information collected continued to increase and with the dawn of the digital age, the first electronic anesthetic records were introduced in the 1980's [3,4]. The electronic record allows automated capture of a large volume of physiologic and mechanical data. It also allows manual inputting of information by the clinician (by keyboard, mouse, touch-screen or microphone) and together, the automated and inputted data are organized to become the electronic anesthetic record which can be both stored in a database as well as printed out in paper form to be put on a physical chart. The electronic anesthetic record, in its current ...

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Documentation on the anesthetic record: correlation with clinically important variables

Cited by 11 publications

References 10 publications

Videolaryngoscopy as a new standard of care

Videolaryngoscopy as a new standard of care

The association of time of emergency surgery – day, evening or night – with postoperative 30‐day hospital mortality

The Anesthetic Record: How Content and Design Influence Function In Anesthetic Practice and Beyond

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