title: [Fundamental concepts in data documentation of anesthesia].
abstract: The record of anesthesia is used for different clinical purposes, most importantly for the control of patient care. Thinking about the minimum contents of an anesthesia record we think that the choice of the minimum contents means a first valuation. The minimum content of the documentation, despite its role as a piece of evidence, is the information that doctors require during treatment. Therefore, the principal content of the documentation may include more than the specialist medical considerations. A precise anesthetic protocol must be kept for every patient, and is an essential part of the responsibilities of a clinical anesthesist.
mesh_terms: D000758:Anesthesia; D004282:Documentation / Q000379:methods*; D001330:Electronic Data Processing; D006753:Hospital Records; D006801:Humans; D008318:Malpractice / Q000331:legislation & jurisprudence; D008501:Medical Records, Problem-Oriented; D012306:Risk; D012984:Software
vernacular_title: Grundvorstellungen über die Datendokumentation während der Anaesthesie.