• Florian Piekarski, George Zhong, Vanessa Neef, Jan Kloka, Florian Wunderer, Patrick Meybohm, Kai Zacharowski, and Florian J Raimann.
• Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany - florian.piekarski@kgu.de.
• Minerva Anestesiol. 2021 Mar 1; 87 (3): 312-318.

BackgroundAnesthetic records facilitate information transmission to the next healthcare professional and should contain all relevant information of perioperative care. While most anesthesia societies provide guidelines for record content, important topics like hemotherapy and hemostatic therapy are not well represented. We considered the quality of anesthetic records with regard to the documentation options for hemotherapy and hemostatic therapy. A secondary objective was to examine guidelines for appropriate recommendations.MethodsAnesthetic records of international anesthesiology departments were evaluated for the presence of 20 defined fields associated with hemotherapy, hemostatic and fluid therapy as well as intraoperative diagnostics and monitoring. International guidelines were reviewed for appropriate recommendations.ResultsA total of 98 anesthetic records from eight countries and guidelines of six anesthesia societies were analyzed. Data fields for red blood cell transfusion have been found in 29.3% (95% CI 0.20 to 0.38), ABO-testing in 6.1% (95% CI 0.01 to 0.11) and indication for transfusion in 2.0% (CI 0.00 to 0.05) of records. Most records contain fields for blood loss (94.4%; 95% CI 0.91 to 0.99) and diuresis (87.9%; 95% CI 0.81 to 0.94). International guidelines that were analyzed do not cover the topic of transfusion, but most give recommendations on basic monitoring, blood loss and fluid management documentation.ConclusionsMost of the evaluated anesthetic records did not contain fields for relevant aspects of perioperative hemotherapy, hemostatic therapy and diagnostics. Guidelines and protocols for anesthetic documentation should include these topics to ensure information transfer and patient safety.

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