Standard Datasets

There is a standard dataset to be recorded peroperatively but additional data may need to be recorded according to the type of operation, monitoring or another special situation. Fig 1 shows an example of a anaesthetic chart.

Data to be recorded during an operation:

Confirmation that standard checks have been carried out on patient, equipment and operation
Place and time of operation (Fig 2)
Personnel involved (anaesthetists, surgeons and anaesthetic assistants)
Type of operation and any apparatus used
Patient positioning
Airway
Venous and/or arterial access
Induction
Regional and/or local anaesthesia techniques

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Fig 1 An example of an anaesthetic chart

Fig 2 The place and time of operation is recorded

Patient positioning is becoming more and more recognized as a cause of morbidity and it is the responsibility of the anaesthetist to position the patient safely. Recording this carefully in the anaesthetic chart may again be useful in the event of future legal proceedings.

Document details of the airway and breathing system, including type of device (for example, LMA), size, any difficulties encountered (may include bag and mask ventilation), and any adjuncts used
Record the grade of intubation as a marker for future anaesthetists and chart any problems encountered for future consideration

Details of anaesthetic technique should be recorded, including methods of induction and all anaesthetic agents given, with dosages. All drugs and fluids given should be clearly recorded, with times of administration.