Introduction

Surgical care is often provided in partnership with anesthesiologists. Care records describe the operation, the anesthetic, staff involved, equipment used and instructions for post-operative care.
Sharing care records is difficult because their structure and content isn't consistent between different care record system providers. This Implementation Guide is an attempt to define a framework for representing the anesthetic care record. In the first phase, only the intra-operative details are in scope. In the next phase, pre- and post-operative phases will be considered.

Scope and Boundaries

Peri-operative care begins with surgical referral and can extend into a prolonged post-operative care period. This IG is resticted to the anesthetic care received during a surgical care episode and additionally, to the intra-operative phase of the episode.
Some parts of the anesthetic care record are covered by existing IGs. For example, data captured from bedside or near-patient monitoring devices is in the scope of the Point-of-Care Device Implementation Guide

Intended Readers

This Implementation Guide is intended for

• healthcare professionals that are involved in the design, specification, procurement and deployment of digital care records, in particular AIMS (Anesthesia Information Management Systems).
• Developers and system integration engineers seeking to exchange structured care data between existing systems
• Developers of new care record systems, in particular AIMS.

The main sections of this IG are:

• Artifacts - Current Artifacts