clinical indicators - Australian and New Zealand College of ...

INDICATOR AREA 2: INTRA-OPERATIVE PERIODAnaesthesia Clinical Indicators Version 5Indicator TopicCompliance of anaesthesia records with ANZCA minimum requirements for anaesthesiainformation.RationaleAn adequate anaesthesia record is an essential part of the patient‟s medical record andshould chart all aspects of management relevant to the anaesthetic.Type of IndicatorThis is a comparative rate based indicator addressing the process of patient care.Desired Rate2.2– HighDefinitions of TermsFor the purpose of Indicator 2.2ANZCA stands for The Australian and New Zealand College of AnaesthetistsSubstantially complies can be interpreted as implying there is sufficient information in thepatient record to identify the patient and understand the treatment provided, Please refer toRecommendations on the Recording of an Episode of Anaesthesia Care ANZCA PS6 (2006)(Appendix 9).Suggested Data Collection Period4–8 weeks (depending on throughput).INDICATORCI 2.2NumeratorDenominatorTotal number of patients who undergo a procedure with ananaesthetist in attendance, where the anaesthesia recordssubstantially complies with the ANZCA requirements for theanaesthetic record, during the time period under studyTotal number of patients who undergo a procedure with ananaesthetist in attendance, during the time period under studyThis indicator can be used to support the following EQuIP5 criteria:1.1.2 Care Planning and Delivery1.1.4 Evaluation of Care1.1.8 Health record documentation1.3.1 Appropriateness of Care1.4.1 Effectiveness of CareACHS Clinical Indicator User Manual 2011 13