Gisborne Hospital Report - Health and Disability Commissioner

Gisborne Hospital 1999 – 2000
Operating Theatre Protocols
There are examples where staff do not date entries or include their
designation.”
Appropriate standards
11.10 The Australian and New Zealand College of Anaesthesia (ANZCA) sets out
minimum requirements for the anaesthesia record (Review P6 (1996)):
“The anaesthesia record is an essential part of the patient’s medical record.
The record should chart all aspects of the anaesthesia management, including
the pre and post-operative management of relevance to the anaesthetist. The
record should follow a logical sequence. It must include prompts to show
essential information regarding the anaesthetic technique and drugs used,
sufficient space to allow the anaesthetist to make more detailed comments
when necessary, and a chart for graphically recording data and attaching
appropriate automated records if available.
The anaesthesia record provides information which may be helpful to all
staff involved in the care of the patient and is of great use to subsequent
anaesthetists (both specialist and trainee). It may also be of medico-legal
importance and can be used for quality assurance and research purposes.
The record must be signed by the anaesthetist.”
11.11 The requirements set out the information that should normally form part of
the anaesthesia record.
“1. Basic Information
1.1 The name of the patient, hospital, record number, age, gender and
weight.
1.2 The dates of the pre-operative consultation and the anaesthesia.
1.3 The name(s) of the anaesthetist(s).
1.4 In the case of trainees, the name of the supervisor and the level of
supervision.
1.5 The name of the surgeon or other proceduralist.
1.6 The procedure(s) planned to be performed and actually performed.
2. Information Prior To Anaesthesia
2.1 Documentation of pre-anaesthesia assessment of the patient, including
the category of patient as defined for example by the American Society
of Anaesthesiologists.
2.2 Summary of general medical status by relevant systems and diseases.
2.3 Concurrent therapy and any known drug or other sensitivities.
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