The Anesthesia Record is a Legal Document
The Anesthesia Record is a Legal Document
Joseph F. Talarico DO
David G. Metro MD
Renee A. Metal JD
In the unfortunate event that you are named in a lawsuit, the anesthesia record can be your best friend—or your worst enemy. Because the anesthesia record is the only document that is continuously and concurrently recorded during the course of surgery, the anesthesia record is often considered the most important document detailing occurrences in the operating room. The anesthesia record is used not only as a record of anesthesia management but also as one of medical and, to a degree, surgical management. For this reason, anesthesia providers must give considerable thought to the development of the anesthesia record as well as to its utilization. It is imperative that the anesthesia record be accurate, clear, and comprehensive regardless of the complexity of the case and regardless of whether complications occurred during the course of the case.
COMPONENTS OF THE ANESTHESIA RECORD
The anesthesia and operative record is the medical and ultimately legal document that records an anesthetic procedure. This record becomes part of the patient’s permanent medical record and should be as accurate and complete as possible. It provides information to other care providers that may influence the postoperative medical decision making for the management of the patient. All anesthesia providers involved in the delivery of care should sign the anesthesia record. All providers signing the chart should confirm the record’s accuracy, and it should include the information identified in
Table 184.1. The old adage, “If it’s not on the chart, it never happened,” is not necessarily true (i.e., intravenous placement procedure does not need to be routinely documented in the absence of complications). It is, however, imperative that all significant occurrences be appropriately documented on the chart.
Although the components of the anesthesia record are virtually universal, there is considerable variation among institutions regarding the information to be included in the record: some records are all-inclusive, attempting to cover every aspect of anesthesia care (e.g., type of laryngoscope blade used, amount of air in endotracheal tube cuff, etc.), whereas others include little more than the minimum. Although there are legitimate opinions that
support both extremes, it is imperative that all sections of the anesthesia form that is in fact being utilized by the medical institution within which one is practicing be timely and entirely completed.
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