Anesthetic and Recovery Room Records

Transcription

1 CATHOL4C MEDICAL CENTER CENTRAL MEDtCAt LIBRARY rd STREE 'JAMAICA, NEW. YORK California Medicine ] Anesthetic and Recovery Room Records JOHN B. DILLON, M., Los Angeles * Anesthetic and recovery room records are important medical documents. In the past they have not been given adequate attention by many anesthesiologists or by most surgeons and other physicians involved in patient care. Anesthetic and recovery room records should be better prepared and better used, for they are an important part of the description of a surgical patient's medical experience. IN 1895 HARVEY CUSHING AND E. H. CODMAN introduced the concept of recording anesthesia. Since that time, many kinds of anesthetic records have been devised and employed with varying degrees of acceptance. The physiologic changes entailed in surgical operation and anesthesia may be so drastic that it would seem self evident today that a detailed record of the course of a patient during these procedures should be kept and studied most assiduously. Unfortunately, anesthetic records generally are poorly made and rarely referred to later unless there is a serious complication. What with the medicolegal implications of anesthesia administration and recovery room observation that are developing, hospital staffs would be well advised to have an anesthetic committee as well as a tissue committee. Perhaps a subcommittee of the hospital executive committee could be formed for the purpose. The committee would have the responsibility of reviewing the completeness and adequacy of the conduct of anesthesia as recorded, as well as the adequacy and completeness of the recording of recovery room supervision. From experience over many years, it is my observation that, with one or two notable excep- From the University of California, Los Angeles, School of Medicine, Department of Surgery/Anesthesiology, Los Angeles. Submitted 18 March Reprint requests to: Department of Surgery, UCLA School of Medicine, Los Angeles, California 924. tions, anesthetic records that were reviewed because of the inference of negligence left a great deal to be desired. Not only are anesthetic records important because of the anesthetic procedure described, they can be equally important in relation to the operation for which the anesthetic was given, since a well kept record describes both. The recovery room record is of great importance to the understanding of the postanesthetic and postoperative course of the patient; and, without such a record, accurately kept, the immediate postoperative condition of the patient is unknown and its influence upon his ultimate course unknowable. There are many anesthetic record forms in existence, some of them excellent, some very poor. As a basis of comparison, samples of the forms advocated by the American Society of Anesthesiology are shown herewith (Charts 1 and 2). One record is for anesthesia during operation and one is especially modified for the equally important conduct of anesthesia during childbirth. These records, if accurately kept, will describe completely the anesthetic and surgical or obstetrical course during that period. Certainly these records are the minimum that should be accepted. The surgical anesthetic record may not describe some exceptional anesthetic and surgical proceedings adequately, and in such cases more sophisticated CALIFORNIA MEDICINE 159

2 NAME ANESTHESIA RECORD AGE DATE CONSENT PHYS. STATUS PREMEDICATION (DRUG, DOSE, TIME, EFFECT) IBUSINESS DATA PLATE Dep~th -a 2 An". tn 3 4 S.P. C A * F I I Start Anes. 34 X 32 Start Op. 3 End An. Temp. A *8 Suction S Rec. Room R 4 2 Rep. Spon. 1n o Cont. SYMBOLS AGENTS DOSAGE ITECHNIQUES REMARKS (INDUCTION, MAINTENANCE, EMERGENCE) c.. E. F. G.._. FLUID SUMMARY DEXTROSE - H2 NASO/OROPHARYNGEAL AIRWAY GLUCOSE - SALINE NASO/OROTRACHEAL- DIRECT- KLIND CUFF- PACK - TUBE SIE SALINE PLASMA IBLOOD OTwHER SURGEON UNDER MASK- DIRECT CONN. TECHNICAL DIFFICULTY ANESTHESIA TIME OPERATION1 LARYNGOSPASM - EXCESS MUCUS RESP. DEPRESSION -2 WANT BUCKING - VOMITING IANESTHESIOLOGIST AMERICAN SOCIETY OF ANESTHESIOLOGISTS. INC.. APPROVED, ISO Chart 1.-Record form for description of clinical anesthesia. HEMORRHAGE - ARRHYTHMIA BRADY}TACHYCARDIA - SHOCK 16 SEPTEMBER 1966 * 15 * 3

3 records may be required, but this would be in- the surgeon informs the patient of the necessity frequent. of the operation and the patient agrees. It is my From the patient's point of view, an anesthetic preference that the preanesthetic evaluation be and, indeed, an operation emotionally begin when made as a progress note of the patient's clinical OBSTETRICAL ANESTHESIA RECORD NAME AGE DATE [CONSENT PHYS. STATUS ROOM NO. HOSP. NO. I&:vinA %PKAVILJA 1P-"- raka I1L Kh UUKAIILM nti-aejtiris VILADUK AED LWo. -n-r PRrAmr-cTwmnI e,nmnlticnm Amn APPICAEAM FnPPATIF L C. DIAGNOSIS MEDICATIONS DURING LABOR DRUGS TIME - AMOUNT TIME - AMOUNT EFFECT AT DEIVERY PROCEDURE PROPOSED INGESTION OF FOOD Aents Fluids Dep of k B.P. V A Stat X An*s. OP. End Oc SEX INFANT` ATA ITEM INFANT INFANT ALIVE OR STILLBORN TIME OF DEUVERY CRYING TIME HEART RATE RHYTHMIC RESP. z. 1 REFLEXES Z MUSCLE TONE COLOR APGAR SCORE INFANT RESUSCITATION INPANT(S) CONDITION WHEN LEAVING DELIVERY ROOM Fstal Ht.Rate on S Rec. Room R R"p. 1 so TIME PLACENTA EXPRESSED MANUAL SPONTANEOUS OXYTOCICS DOSE ROUTE TIME AGENTS. FLUIDS DOSAGE TECHNIQUES REMARKS (INDUCTION, MAINTENANC, EMERGENCE) L a SYMBOLS C. DESCRIBE REGIONAL BLOCKS {INCLUDE DIFFICULTIES) NO ANESTHESIA ADMINISTERED PROCEDURE PERFORMED OBSTETRICIAN ANESTHESIOLOGIST ood11 AFOF5 193 AMRICAN SOCIEfY OF ANKITHMOLO5tIS1 INC.AND AMNCN CO.LLE OF OUTMCIANIS AND TNCOLO5ISI PHYSICIAWU RSCOES CO FT. ILLINOIS - PSINTIS Is s. O55TETICj Chart 2.-Record form for description of anesthesia for description for obstetric care. CALIFORNIA MEDICINE 161

4 record. My reason for this is that as a progress note it is seen and read; whereas, if it is on the reverse side of the anesthetic record it is frequently ignored, because it is out of sequence in the patient's record. The anesthetic record begins when the patient is seen in the induction area, whether it is the patient's room, operating room or delivery room corridor, emergency room, operating room or labor or delivery room. The time that the anesthetist be- NURSES' RECOVERY ROOM RECORD Name Age Room Arrived in R.R. at M. P.M. Type of Delivery Obstetrician Date ADMISSION SUMMARY Genoral Appearance Patient Responding Reflexes Airway Devices Respiration Dentures Fluids Retching Vomiting Other Comments Bladder PROGRESS IN RECOVERY ROOM Fundus Vaginal Bleeding TIME B. P. V 22 Pulse Reasp. Admission A Transfer T 2 ISO MAINTENANCE (Remarks) Suction Remarks and Symbols DISCHARGE SUMMARY M. Patient Transferred to at P.M. Vital,Signs Dentures General Appearance Fluids Oxygen Therapy Complaints of Patient on Transfer Summary Notes: Chart 3.-Chart for description of recovery room care. (.115 BACK) 162 SEPTEMBER 1966 * 15 * 3

5 gins his ministrations should be noted. This usually is or should be related to the observation of the effects of the premedication, if any, and the observation of the vital signs, pulse, respiration and blood pressure. The time of starting an intravenous infusion, if any, should be noted and the composition and the amount of fluid used should be stated. If there is a time lapse between the original observation and actual beginning of administration of the anesthetic agent, the time and cause should be noted-for example: "Operating room not ready." Pulse and respiration should be recorded as well as systolic and diastolic blood pressure every five minutes, even though pulse and respiration may be mentally noted continuously via the precordial stethoscope. I would not accept systolic blood pressure estimated by the oscillatory method as valid, although there are times when the palpated systolic pressures may be the only pressures obtainable-but this is rare. Only an unusual event-fully explained in the recordshould be acceptable reason for not recording systolic and diastolic blood pressure at five-minute intervals. Dosages of drugs and manipulations such as intubation and positioning should be noted accurately in relation to time and vital signs. The use of additional monitors such as body temperature, electrocardiogram and venous pressure should be noted. The time of the incision or manipulation or other treatment by the surgeon, obstetrician or diagnostician should be included in the record. Frequently in many of the procedures now in use, the length of time taken in preparation of the patient is significant and the period should be accounted for on the anesthetic record. If changes occur in the vital signs, notes should be made as to probable cause and as to what therapy was applied, if any. Changes in blood pressure and pulse are frequently related to lightening or deepening of anesthesia or to traction reflexes, blood loss and a variety of other phenomena. In such circumstances, notes should be made as to cause and therapy. Continuous observation will show that there is seldom an uneventful anesthetic or surgical, obstetrical or diagnostic procedure and any anesthetic record that shows none is highly suspect. The time of the termination of the procedure for which anesthesia is given should be noted and the condition of the patient stated. The record should say what time the patient was turned over to the recovery room personnel or floor nurse and it should include the pulse, respiration and blood pressure at that time, along with notes about anything out of the ordinary in the patient's condition. The recovery room record or postanesthetic record should be kept with the same detail that the anesthetic record has been kept. There are special recovery room records (Chart 3) but actually the anesthetic record is perfectly satisfactory and is a logical continuation. The records may be combined sequentially on the same record with appropriate notation, or a new sheet may be started. If the patient's condition demands, the anesthesiologist may well be required to care for him in the immediate postanesthetic period. Exactly when the anesthesiologist may terminate this supervision will always be a matter of judgment on his part. This decision depends upon many factors not part of this discussion. I believe it is desirable that removal of the patient from the recovery room be on order of the anesthesiologist or surgeon, and that an appropriate note should be made in the record. The anesthetic and recovery room record is a very important document relating a very critical part of any patient's medical care, but its value is only as great as the care and understanding with which it is made. It is suggested that hospital staffs give these records scrutiny to -the end of seeing to it that they are of a high order. CALIFORNIA MEDICINE 163