Record

The anesthesia record is the medical and legal documentation of events while a patient is under anesthesia. It should contain a detailed and continuous account of all drugs, fluids, and blood products administered and procedures undertaken, and also includes the observation of cardiovascular responses, estimated blood loss, urine output and data from physiologic monitors while a patient is under anesthesia.

Traditionally handwritten on paper, the anesthesia record is increasingly being replaced by an electronic record as part of an Anesthesia Information Management System (AIMS), especially since 2007. An AIMS is any information system that is used as an automated electronic anesthesia record keeper (i.e., connection to patient physiologic monitors and/or the anesthetic machine) and which also may allow the collection and analysis of anesthesia-related perioperative patient data gathered from monitors and/or the anesthesia machine. These systems typically run on medical-grade hardware in the operating room. AIMS can be stand-alone systems or integrated modules of a hospital information system. AIMS have several benefits to the anesthesia departments as well to the hospital administration as documented in the scientific literature:

• Reducing anesthesia-related drug costs
• Increased anesthesia billing and capture of anesthesia-related charges
• Increased hospital reimbursement through improved hospital coding
• Improved efficiency of the physicians involved in anesthesia and surgery through transfer pricing
• Improvement of the data quality of the intraoperative anesthesia record
• Support training and education of the anesthesia workforce 
• Support of clinical decision-making 
• Support of patient care and safety
• Enhancement of clinical studies
• Enhancement of clinical quality improvement programs
• Support of clinical risk management
• Monitoring for diversion of controlled substances