The uses of the anesthesia record.
The typical, handwritten anesthesia record of the 1980s does not satisfy its many users. The document is used for clinical care by the anesthetist, nurses, physicians, and technicians in postanesthesia, intensive, and postoperative surgical care units; for historical information by the billing officer, the statistician, and the anesthetist in preparation for a future anesthetic; and for the review of the quality of care by clinical peers and lawyers. For all of these users the typical record contains some to much unnecessary information and lacks some to much needed information. Electronic capture, storage, retrieval, and formatting of data can generate electronic displays or paper records tailored to answer the needs of specific users. The anesthetist in particular will benefit from a well-designed system that takes the place of the traditional handwritten anesthesia record.
Gravenstein
J S
JS
Department of Anesthesiology, College of Medicine, University of Florida, Hillis Miller Health Center, Gainesville 32610.
D000776:Anesthesiology; D003199:Computer Systems; D003625:Data Collection / Q000295:instrumentation*; D006751:Hospital Information Systems / Q000592:standards*; D008499:Medical Records / Q000592:standards*; D008501:Medical Records, Problem-Oriented / Q000592:standards*; D009870:Operating Room Information Systems / Q000592:standards*