Why anesthesia records are so difficult to read

The Gist
• Anesthesia records are hard to read because of charting limitations.

By Pat Iyer, RN, MSN, LNCC
© The Medical-Legal News

Anesthesia records contain large amounts of data recorded in a cramped space. The space for writing information is often smaller than is practical. There is usually insufficient room to record events when things go wrong, and it is rare for a form to allow much space for additional notes.

The anesthesia record is notable for using graphic recording techniques, abbreviations and symbols, some of which may not be standardized. Although the format of the anesthesia record page is designed to handle many parameters and pieces of information, it is impossible to record every single aspect of the anesthetic course. While vital signs are typically recorded every five minutes, they may be monitored more frequently. Blood pressure determinations recorded every five minutes may reflect an “average pressure” from measures obtained at two- or three-minute intervals, or even more frequently when a patient is unstable.

Sudden changes in the patient’s condition direct attention away from the recording of data and toward administration of medications or fluids, and the completeness of the anesthesia record is affected.

Automated anesthesia records ( AAR ) are available in some settings, but are not widely used. Information from electronic monitors is automatically transmitted to a computer. A keyboard is used to input additional information.

The AAR has some drawbacks. Interference with electronic signals (artifacts) may require editing by the anesthesiologist. The most striking example of this problem occurs during the surgeon’s use of electrocautery to cut tissues and stop bleeding. The EKG signal is lost during this time, resulting in an erroneous heart rate recording, possible erroneous recording of heart arrhythmia, and triggering of alarms. The provider must then manually indicate the presence of electronically generated artifacts.

Other artifacts may be present on the record without being recognized and identified by the anesthesiologist. These drawbacks may be outweighed by the advantages of a more accurate recording and significant time savings. It has been estimated that between 15 and 20 percent of a provider’s time is spent documenting and recording events and data, and it has been argued that relieving the provider of a task will allow for more supervisory and cognitive activity, thus preventing crises.

Decoding Anesthesia Records

Anesthesia records are among the most complex of forms found in medical records. The key to understanding them is to recognize that forms are generated at two phases of the surgical experience: 1) preoperatively during the anesthesia evaluation, and 2)  intraoperatively during the administration of anesthesia.

The preanestheisa assessment collects data about the patient’s medical and surgical history, anesthesia history, vital signs, height, weight, allergies and details of any family members’ reactions to anesthesia.

Intraoperative anesthesia records invariably consist of a grid with the time across the top in five minute increments, and a column down the left side to record information about medications or anesthetic gases and patient data. The grid starts with the time the anesthesia begins. Symbols typically are used to indicate various aspects of a patient’s status.

The move toward computerizing medical records may result in wider spread use of AAR . However, whether handwritten or computer generated, it is likely that anesthesia records will remain challenging to interpret. •

 Patricia Iyer, RN, MSN, LNCC is president of Med League Support Services Inc.; info@medleague.com.