Anestesia e Pesquisa Clínica
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The Anesthetic Record: How Content and Design Influence Function In Anesthetic Practice and Beyond

Karen Raymer

The anesthetic record is used in the course of every anesthetic and its origin can be traced to the earliest days of the practice of Anesthesia. Primarily a medical record, it fulfils other roles: patient-safety tool, medico-legal document, and research and quality assurance aid. After detailing these functions, the author aims to identify the content requirements for the anesthetic record and explain the factors that affect accuracy and completeness. The impact of format on the functions of the anesthetic record is explored. In particular, handwritten and electronic formats are compared and contrasted. With a fuller knowledge of these issues, the Anesthesiologist (individually, departmentally and professionally) will understand that the design and use of the anesthetic record warrants attention to ensure its optimal contribution to patient care.