An attempt to generate a semiautomated anaesthesia chart using the SIRECUST 4000 system

As a result of the doctor-patient contract the obligation of the treating physician in an Austrian hospital arises to provide written documentation of the perioperative period from the point of view of anaesthesia as part of the patient's chart. This obligation is included in the Austrian hospital legal code for hospital care (Riegler, 1987). Anaesthesia-related documentation starts with the preoperative evaluation. The anaesthesia chart comprises all entries, events, and complications which occur during the perioperative period. Thus the anaesthesia chart is a legal document serving as evidence in case of court action regarding events during or after anaesthesia. Therefore the anaesthesia chart has to provide accurate, complete and legible information (Osswald, 1987). In Austria, all patient records have to be stored for 10 years. Therefore storage of data as well as easy access with the help of central documentation by a computer would be valuable. Also it is useful to provide economic and scientific statistics for studies and clinical investigations (Pollwin et al, 1987). As our old handwritten anaesthesia chart is not very objective and accurate we have attempted to create a new protocol to fulfil our requirements