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Chapter-03 Guidelines for Documentation of Anesthetic Care

BOOK TITLE: Practice Guidelines in Anesthesia-2

Author
1. Bhatia Pradeep
2. Chhabra Swati
ISBN
9789352703067
DOI
10.5005/jp/books/14207_4
Edition
1/e
Publishing Year
2018
Pages
10
Author Affiliations
2. All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
Chapter keywords
Anesthetic care, documentation, regional anesthesia, documentation system, legal implication, anesthesia information management system, AIMS, electronic health record, EHR

Abstract

This chapter describes the guidelines for documentation of anesthetic care. Documentation is a material that provides official information or evidence or that serves as a record. Documentation in a medical record broadly includes a patient’s health history (present and past), examinations, investigations, interventions, and outcomes. This chapter covers the areas of services by anesthesiologists, regional anesthesia, documentation systems, and legal implications of anesthesia documentation. Anesthesia is a specialty involving a high risk of complications. Legal issues are encountered in anesthesia practice every now and then. Like any other medical record, anesthetic record is also a legal document and bears legal implications.

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