Anaesthetists Handbook - MEDICAL EDUCATION at University ...

Miscellaneous issuesThe following represent data items that are audited for CNSTpurposes. Only two of them were present on all anaesthesia charts inan audit in 2008. Please help us to do better.• Patient name in full.• PID.• Clinical history (past medical history etc.).• Drug history.• ASA grade.• Allergies.• Results of pre-operative investigations.• Anaesthetic risk.• Name of anaesthetist.• Signature of anaesthetist.• Surgery performed.• Urgency of procedure.• Drugs (with doses) given during anaesthesia.• Monitoring data.• Blood loss (or “nil”).• Urine output (or “nil”).• IV fluid (or “nil”).• Use of specialised equipment.• Method used to secure and maintain airway.• Patient positioning.• Post-anaesthetic instructions.• Date of event.• Time anaesthesia started.• Time into theatre.• Time of incision.• Time surgery finished.• Time anaesthesia finished.• Pre-medication.• Cannulation.• Record of vital signs.• Anaesthetic technique used.• Recovery observations.• Recovery drug record.230 Anaesthetists Handbook January 2010