The anaesthesia record: what to document and why

An anaesthetic chart can hold plenty of values and still say little about what happened to the patient. A useful record shows the course over time. How did the patient start? Which drugs were given? What changed, what was done, and how did the patient respond?

In my experience, across different clinical settings, one of the biggest problems is missing or interrupted records. When a procedure gets more demanding, documentation can slip. That is understandable, because treating the patient comes first. The challenge is to organise the work so those moments are recorded too.

During the procedure, a visible timeline helps you link changes to interventions. At handover, the colleague taking over can follow the patient's course without relying only on what they are told. Later, the record lets you review decisions, discuss complications and plan future procedures.

The AAHA guidelines include documentation of parameters during anaesthesia and recovery as part of perianaesthetic care.¹ A Canadian survey found that anaesthetic records were not used systematically. Its results cannot be generalised worldwide.²

What goes in the record

The record starts before induction. Patient identification, weight, procedure, preanaesthetic assessment, identified risks and the plan give context to everything that follows.

With drugs, keep what was planned apart from what was actually given. The drug name, dose with its unit, route and time should make each administration clear. Concentration and volume help to check what was used.

During anaesthesia, each parameter needs a time and a clear label. "Blood pressure" on its own may not be enough. The reader needs to know which value was recorded and by what method. Anaesthetic adjustments, ventilation changes, fluid therapy and other relevant events go in the same sequence.

Recovery stays on the record too. Note clinical progress, pain assessment, support given, relevant events and the handover of responsibility.

How often to record

The 2025 ACVAA guidelines separate continuous vigilance from periodic documentation. In general, they recommend recording four values every five minutes: heart rate, arterial blood pressure, peripheral oxygen saturation and end-tidal carbon dioxide. Other physiological variables should be recorded at least every fifteen minutes.³

These intervals are about what gets written down. The patient is still watched continuously, and the plan should follow the clinical condition. Events and interventions get their own times, even between scheduled entries.

Take fifteen-minute intervals as an example. That gives only four recording points an hour, plus any initial entry. A transient change may not show up in any of them. So the periodic values need to be supplemented by the events and interventions.

Gaps are a problem of their own. When a value is missing, the reader may not know why. Was the patient stable? Did the measurement fail? Or did nobody manage to write it down? Where possible, note the reason.

The record should also show what was measured, what was observed clinically and what was added later. Reconstructing an episode from memory is different from documenting it at the time.

An organised chart puts the timeline on the page. Without it, whoever is monitoring has to hold earlier values, changes and responses in their head. I notice this difficulty most in long procedures.

Paper or digital

Chart layouts and abbreviations differ between teams. This can make a record harder for a colleague to read, and episodes harder to compare. A common structure helps: labelled fields, consistent units and a legible time scale. Each practice can keep its own sheet. The essential information just has to be recognisable and interpretable.

Paper is simple and does not depend on computer systems. But it needs organisation. The chart has to be filed, found again and linked to the clinical record. In my experience, scanning after the procedure does not always happen.

Filling in the chart also takes attention. On a graphical chart you find the variable, find the point for the value and the time, and mark it. Meanwhile your attention is split with watching the patient. In my experience, this can get harder when responsibility changes hands and colleagues use different symbols, notes or ways of filling in the chart. A clear structure and shared conventions can help the next person follow the record. Handover is still needed.

Scanning keeps the document. But an image does not turn itself into structured data. Getting the values out may take transcription or optical character recognition, and then checking. A paper-only archive also takes up space. It can make looking something up years later more laborious.

Digital formats can make information easier to search, organise and reuse. They do not guarantee quality. One before-and-after study at a university hospital introduced an electronic record. Afterwards, some fields were more complete and others less complete.⁴ That result does not show fewer complications.

Whatever the format, values have to be checked, times kept and corrections identifiable. Automated capture needs review as well.

A record the team can keep up

In practice, I suggest four habits. Prepare the chart before induction. Agree who documents. Use reminders where they help. At handover, check that the essential information is accessible.

The aim is a record that is legible, coherent in time and complete enough to understand the case. VetNoa is being developed to support data capture from existing monitors. It is also meant to organise information over the course of a case. That capture still needs clinical verification.

Anaesthesia record checklist

Adapt it to the patient, the procedure and your practice's protocols.

• Patient and episode identification; date, procedure, weight and responsible team.
• Preanaesthetic assessment, ASA classification, risks and plan.
• Available initial values and relevant context.
• Planned medication distinguished from administered medication; drug, dose and unit, concentration, volume, route and time, as applicable.
• Relevant times: premedication, induction, start and end of the procedure and anaesthesia, extubation.
• Heart rate/rhythm, blood pressure and method, SpO₂, EtCO₂, respiratory rate, temperature and clinical assessment, as applicable.
• Oxygenation, ventilation, maintenance anaesthesia and fluid therapy, with changes identified in time.
• Events, interventions and subsequent progress.
• Unavailable measurements or interruptions identified, without filling gaps with presumed normality.
• Recovery, pain assessment, support and handover.
• Legibility, units, times, authorship and identifiable corrections.
• Record linked to the clinical history and accessible for future consultation.