1. Significance and value of anesthesia record: "Anesthesia record sheet" is one of the important parts of patients' medical records, and it is a comprehensive real-time record of patients' anesthesia process, which can timely understand patients' reactions to anesthesia and surgery. Intraoperative treatment (blood transfusion, infusion volume, therapeutic drugs, etc.). ) recorded in anesthesia records can provide reference for postoperative treatment. It is also an important material for future case review, scientific research statistics and even medical dispute investigation. It should be filled in carefully, comprehensively, accurately and truly by the resident (senior physician) who participates in anesthesia, and it is not allowed to be altered or forged.
Second, the front of the anesthesia record sheet
The front of anesthesia record sheet should include the following three items.
(1) General project
Name, gender, age, weight (adults are not required, heart patients and children should fill in), ward, bed number, operation date, hospitalization number, clinical diagnosis, operation name, physical condition, mental state, anesthesia effect, complications, medication before anesthesia, operator's name, anesthesiologist, instrument nurse and/or visiting nurse.
(2), anesthesia and surgery
1. Anesthesia method: record the full name, such as intravenous inhalation anesthesia, controlled hypotension, cooling anesthesia, etc.
2. Anesthetic medication: record the name, dosage, time, concentration and route of administration.
3. Anesthesia ventilation mode: record the name of the method, such as back and forth closing, opening and closing circulation, T tube device, tidal volume, frequency, CMV, PEEP and CPAP.
4. Intubation: trachea, bronchus (unilateral and double lumen), route (radial mouth, nose and tracheostomy), anesthesia mode (inhalation or venous induction, awake surface anesthesia) and methods (bright vision, blind exploration, etc.). ), catheter diameter (F number or ID number), intubation and extubation time.
5, anesthesia induction and withdrawal time, operation start and end time.
6. Monitoring record of respiratory and circulatory changes during anesthesia: when the condition is stable, it is measured every 5 minutes. When the condition changes greatly, it should be measured and recorded at any time. Before the patient leaves the operating room, the above measurement and recording work should not be suspended. After the patient is carried to the cart, the blood pressure should be measured and recorded again. For sedation/analgesia, vital signs should be recorded at least every 5 minutes, and OAA/S score should be recorded every 30 minutes.
7, the main steps of surgery, need to indicate the special circumstances, such as massive blood loss, pneumothorax, etc. , you can number it in the notes at that time and indicate it on the right.
8. Intraspinal anesthesia: record the puncture point, intubation direction and depth, and anesthesia plane.
9, record the patient's body temperature, oxygen inhalation, respiratory management and important steps of surgery.
10, special circumstances during operation (such as laryngeal spasm, chills and convulsions).
1 1, intraoperative accidents: aspiration, total spinal anesthesia, cardiac arrest, etc.
12, posture: posture and intraoperative changes should be explained.
(3) After anesthesia.
1. Awakening from general anesthesia at the end of operation: not awake, initially awake or fully awake.
2. The range of sensory block of spinal nerve at the end of operation.
3. When leaving the operating room: the degree of awakening, breathing, blood pressure, SpO2 _ 2, etc. when the patient was moved to the hospital bed for the last time.
4, anesthesia effect
Third, the back of the anesthesia record sheet (abstract)
(1) Excerpt from interview before anesthesia
1. Chief complaint and brief medical history: including coexisting medical history related to anesthesia, positive signs and examination (heart, lung, liver, kidney and central nervous system).
2, preoperative general situation and mental state
3, preoperative medication history, allergy history, surgical anesthesia history.
4, organ function correction and current functional status evaluation.
5, anesthesia method, anesthetic, preoperative medication selection basis.
(2), remember after anesthesia
1. Analysis of the effect of medication before anesthesia
2, anesthesia operation process is smooth
3, the patient's tolerance to anesthesia, intraoperative problems, changes in the condition and treatment analysis, what are the lessons?
4, infusion, blood transfusion, medication, oxygen treatment is correct and reasonable.
(3), at the end of the operation, write a summary on the home page and copy page, hand in the attending physician's signature, and then hand it over to the nurse.
(4), anesthesia record summary should be completed at the end of anesthesia.
(5) Put the first page of the record sheet into the medical record, and copy one page for archiving.
Four, monthly anesthesia records in the first Monday of the following month by Dr. Wei Xin Chuan and nurse Xiong is responsible for, and transferred an attending physician, spot check all records 65438 00%. The spot check method is determined by drawing lots according to the mantissa of hospitalization number. The results will be announced at the departmental morning meeting and the afternoon general meeting the next day.