THE ANESTHESIA PROTOCOL FOR COMPUTER-AIDED DOCUMENTATION AND QUALITY-CONTROL .2. COMPUTER-AIDED QUALITY-CONTROL

This paper describes a medical documentation system that has been developed since 1985. The major component for the Anaesthesiological Department is an anaesthesia protocol that is keyed-in immediately after induction of anaesthesia. The data processed in the computer are discussed on an individual basis. The objectives of the system are: 1. Collection of all anaesthetic-related data. 2. Personnel-saving documentation. 3. Provision of data-based performance statistics and a basis for the establishment of personnel requirements. 4. Possibility of automatic billing. An anaesthetic protocol capable of being processed by an optical character reader (OCR) provides the data for medical quality control. All events - including those that represent a danger to the patient - are registered. The significance of each event for the patient is scored on the basis of a scale. A detailed, free textual description of any critical events is also possible. The evaluation of the data thus generated can permit the establishment of any desired inter-relationships involving the anaesthesia, the state of the patient, the level of training/experience of the anaesthetist, and any events that might occur.