Intraoperative Charting Requirements

The first description of an automated intraoperative anesthesia recording machine was noted as early as 1934. ¹ The device recorded tidal volume, FiO ₂, and blood pressure. Since then, many attempts have been made to replace the paper record. One group even used video recording machines to record all of the information presented visually to an anesthesiologist from the monitor screens. ² Despite the advances in computer and information technology, the paper record has endured as the medium of choice to document the intraoperative experience. The first modern anesthesia information systems were essentially intraop-erative record keepers—with the ability to automatically capture physiologic data from monitors and other devices such as ventilators. From those humble beginnings, intraoperative record keepers have evolved into perioperative information systems that allow clinicians to manage the patient throughout the entire surgical experience.

Several drivers have contributed to this evolution in function. First, as data interfacing has become increasingly secure and prevalent, more physiologic monitoring is being automatically captured into the anesthesia record instead of being transcribed. Second, an enhanced understanding of anesthesia workflow by the AIMS vendors, in partnership with anesthesiology departments, has prompted these systems to become comprehensive anesthesia workflow tools rather than merely intraoperative record keepers. Finally, hospital leadership is looking to the ORs for revenue generation. The OR is well recognized as a financial engine that helps to drive the healthcare enterprise, and anesthesia is a key lubricant of this engine. As such, anesthesia information systems are incorporating more financially savvy functionality, and AIMS content is becoming more billing friendly.