Anaesthetists Handbook - MEDICAL EDUCATION at University ...

Miscellaneous issuesDifferent clinical areas might have different records needing to becompleted.We are continually audited against chart standards for CNSTpurposes. You should make sure that your name, grade and GMCnumber are legibly printed on every patient record that you complete.Repeated audits have shown that records are completed poorly withmandatory items often omitted. This leaves you open to criticism andvulnerable to a potential court case.Items that are often missed out are:• Using black ink.• The name and grade of the anaesthetist in block letters.• Estimated blood loss.• Intraoperative and postoperative fluids.• Postoperative oxygen prescription.• Postoperative instructions for recovery staff.• Details of handover to another anaesthetist.Remember to include on the record details of:• Your GMC number.• Any discussion with senior colleagues and their names.• Care discussed with StR3+ if ASA 3, or consultant if ASA 4 orASA 5.• Name of responsible consultant.• Discussion and decisions about levels of monitoring.• Discussion and decisions about postoperative care.Please make sure that you are aware of the standard of recordkeeping expected of you (based on RCA & AAGBI guidelines).We audit anaesthesia records on a random basis. The results are aregular item in clinical audit meetings.Anaesthetists Handbook January 2010 229