UNIFORM RECORD KEEPING IN ANAESTHESIA: NEED OF THE HOUR
Dr Rajiv Chawla, Professor
Dr Manoj Bhardwaj, Assistant Professor
Department of Anaesthesiology & Intensive Care
G B Pant Hospital
New Delhi 110002
Email: email@example.com; firstname.lastname@example.org
If you did it, write it down; if you don't write it down it didn't happen.
If you did it, bill it; if you don't bill it, it is a hobby, not a business.
An artist always signs his work”
- "Mark Twain"
This old dictum is still applicable for all anaesthesiologists of this new millennium. Even today,
the anaesthesia record is an essential part of the patient‟s medical record. Even the best of
anaesthetic care cannot be defended or referred to if there is no clear record that such care took
place. This applies to pre-operative evaluation, postoperative care as well as intra-operative
management. The essential purpose of maintaining anaesthesia record is to document how an
individual patient responds to anaesthesia and surgery.
Giving anaesthesia to a patient is a „process‟. It follows a logical sequence. This includes pre-
anaesthetic check up (PAC) and optimization, planning of anaesthesia technique based on PAC,
administration of anaesthesia, and post –operative management. The findings and interventions
undertaken during this process must be documented in what constitutes an „anaesthesia record‟.
The anaesthesia record is a generic document which must be used for a wide variety of patients
and procedures. An ideal record system is expected to contain relevant information of the patient,
procedure, pre-anaesthetic evaluation, anaesthesia technique details, intra-operative events/
complications, and post operative instructions of the anaesthesiologist.
Review of literature reveals that some professional bodies of anaesthesiology in developed
nations have formulated various guidelines and recommendations on anaesthesia record keeping.
These bodies provide an advisable course of action. They list the basic minimum information
that must be recorded as ‘core information’. The core information includes details about patient
personal data, documentation of pre-anaesthetic assessment including the physical status of the
patient, plan of anaesthesia, possible outcomes risk. It also includes detailed anaesthesia related
information. This has helped to establish minimum standards in anaesthesia record keeping in
However, until date, there are no guidelines / recommendations on record keeping by Indian
Society of Anaesthesiologists for its members. To find out the content of anaesthesia records in
Delhi, we planned a study in the Department of Anaesthesiology and Intensive care, G B Pant
Hospital, New Delhi. A survey was conducted to evaluate the information collected in the pre-
anaesthesia evaluation forms and anaesthesia record forms of 26 leading medical institutions of
Delhi. These included autonomous institutions, corporate hospitals, medical college associated
hospitals, hospitals managed by NCT of Delhi, and Municipal Corporation of Delhi.
The results of this survey revealed that there is no uniform anaesthesia recording system in the
city of Delhi. It also reveals that there is lot of variability in the anaesthesia related information
collected by different institutions. The record system was not perfect. None of the forms had
space to record information on „anaesthesia machine check‟. In a large majority of forms the
designation/ hierarchical status of the anaesthesiologist was not stated. Important details required
as core information was missing in a large majority of forms.
In order to make the anaesthesia record keeping more accurate and perfect, it is mandatory that
there should be a uniform pattern of anaesthesia record keeping. Uniform record keeping has
definite advantages. These are listed in table 1. One can see that for clinicians, uniform record
keeping will improve patient care, medical education and research. For the health administrators,
uniform record keeping will help in better resource allocation and utilization. A well-designed
form serves as a printed checklist for the anaesthesiologist. In the pre-operative evaluation, it
ensures that all the relevant questions have been asked. In the intra-operative period, it reminds
the anaesthesiologist to perform certain tasks.
Uniform record keeping also has a role to play in safeguarding anaesthesiologists in medico-
legal cases. The practice of anaesthesia is amongst the most potentially dangerous disciplines in
medicine: both for the patient and the anaesthesiologist. The quality of the anesthesia record
affects the defensibility of that record in a court of law since it is the most credible source of
facts about a case. It has been said, "Good charting helps, bad charting hurts, and no charting
A complete anesthesia record must be created during the operation which meets both the
demands: for medical purposes and for legal purposes. The record must be made
contemporaneously and continuously. The record must provide a detailed account of what took
place during the course of the treatment and management of the patient. While patient care takes
precedence over record keeping, every effort should be made to keep the anesthesia record as
current as possible. Information recorded only on the basis of the anesthesiologist‟s memory is
suspect. An illegible or a scantily complied anaesthesia chart is likely to be taken as indirect
evidence of shoddy or inattentive care.
After a bad outcome, the anesthesiologist will often become enveloped in a 5-7 years period of
anxiety, stress, anger, disappointment and frustration, which often results in depression, eating
disorder, hypertension and alteration in interpersonal relationships. There are no strategies,
which can guarantee that the anesthesiologist can prevent a bad outcome. However, there are
strategies that enable the anaesthesiologist to minimize the chances of a bad outcome. One such
strategy is „uniform anaesthesia record keeping’. Unfortunately, this, as our survey results
shows, is a major deficiency in our prevailing system. On this matter of concern, there are certain
obvious questions that need to be answered in the subsequent paragraphs.
Is uniform anaesthesia record keeping possible? :
Yes, it is .The medical disciplines of trauma, resuscitation, and airway management have
adopted uniform reporting system. The uniform reporting in these systems is known to serve as a
tool for quality control, scientific evaluation and allows for intra-system evaluation and inter-
system comparisons. It has demonstrated its potential in these fields. These, incidentally, are
disciplines where anaesthesiologists play a leading role.
Who implements uniform anaesthesia record keeping in India?
Broadly speaking, the task of implementation can be undertaken by any of the three groups: -
the professional groups, the regulatory agencies, or the court/ government directive.
Ideally, the Indian Society of Anaesthesiologists should take the responsibility of implementing
this system. This record keeping format devised by ISA shall be one which is “of the
anaesthesiologists, by the anaesthesiologists, and for the anaesthesiologists”. A recording format
devised by the regulatory bodies (like Medical council of India or Delhi Medical Council) or
following a directive from the court will miss a democratic feel! It is likely to make
anaesthesiologists feel uncomfortable, as it is a decision that has been „thrust upon‟ and not taken
A word of caution:- Come what may, uniform reporting in anaesthesia will soon get into our
specialty. It can only be delayed by inaction on our part. The issue is „whether we do it
ourselves‟, or „someone else‟ (read as - courts or government directives) gets it done from us.
Uniform Reporting in Anaesthesia: A Template
This work was presented at the recently concluded 45th Annual Conference of the Indian Society
of Anaesthesiologists (Delhi Chapter). The response of the members and subsequent discussions
was encouraging and motivating. The authors therefore, set out to devise „Pre Anaesthesia
Evaluation Chart‟ and „Anaesthesia Record Chart‟ that can be adopted for uniform reporting.
While devising these forms, valuable information gathered from the survey of data of 26 medical
institutions was utilized. In addition, inputs have also been put in after internet search and
discussions with leading anaesthesiologists. These forms are only a template. (Copy enclosed as
„inserts‟; also available on ISA Delhi website) Obviously, it cannot and will not meet the
requirements of every case scheduled for anaesthesia. That is also not the aim of designing these
forms. If, however, they are found to be applicable to a large majority of patients who are
administered anaesthesia in city of Delhi, the purpose is served. On this issue its only you: you
the practicing anaesthesiologists of Delhi who can provide a valuable feedback. Your
suggestions will help to suitably modify these forms. Once approved by the ISA (Delhi Chapter),
the anaesthesiologists of Delhi may soon have a uniform reporting system in anaesthesia: which
is need of the hour!
(Please send your feedback by post or email as stated above).
Table 1: Advantages of Uniform Record Keeping
• Provides common language : aids communication
• Determine risk of anaesthesia
• Predict patient outcome
• Help evaluate and standardize treatment within the same centre and between centres
• Protocol based management
• Quality assurance
• Accurate and consistent information
• Help in planning and allocation of resources
• Evaluate and validate new methods and research
• Facilitates epidemiologic study
• Uniformity of patient care
• Uniformity in teaching and training standards
• Key document for medico-legal support