Page 28 - Part 1 Anesthesiology Common Risk Issues

SVMIC Anesthesiology: Common Risk Issues

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 re-evaluation

• 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)

• Medications administered: dose, time, route, and response
(where appropriate)

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