Page 27 - 2022 Risk Basics - Anesthesiology

SVMIC Risk Basics: Anesthesiology

write data from the main hospital clinical data repositories.

While the core functionality of an AIMS centers on the
automatic and reliable capture of intraoperative patient data,

most AIMS today also include modules for storing pre- and

postoperative patient information. The information captured by
an AIMS is usually stored in a relational database that

supports multi-user access along with archival and backup
capabilities. While these databases are most often accessed

using a vendor’s commercial front-end application, they may

often also be accessed directly using standard database tools.

If you are using an electronic Anesthesia Information
Management System (AIMS), the automated real-time input of

vital signs data may increase the accuracy of the anesthesia
records. However, a free text note about an event may still be

appropriate, and preferred in some instances. In the event of a
claim or lawsuit, it is always preferable that the documentation

evidence individual patient care. Perioperative assessment and

management guidelines for various types of surgery and
patient risk factors should be developed, continuously updated,

and made available online to all providers within the institution.

According to the ASA, at the start of and during anesthesia
care and anesthesia procedures the following should be

documented:

 Patient reevaluation

 Confirmation of availability of and appropriate function of

all necessary equipment, medications, and staff

 Physiologic monitoring data (e.g., recording of results

from routine and non-routine monitoring devices)

Page | 27