Development of Anaesthesia Electronic Medical Record

Department of Anaesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University provides services to patients undergoing operative procedures in many fields; such as Traumatic surgery, Orthopaedics surgery, Eye surgery, Ear, Nose and Throat surgery, Plastics surgery, Cardio-thoracic surgery, Neurosurgery, General surgery, Urological surgery, Head and Neck surgery, Paediatric surgery, Obstetrics surgery, Gynaecological surgery, Electro-convulsive therapy, Radiological services, Endoscopic centre, Intensive Care Unit, Acute Pain service, Pain Clinic and Pre Anaesthesia Assessment Centre.

Normally, anaesthesia personnel make a patient information record during the surgical procedure. Pre and post-operatively, they visit patients to make sure that their customers are well informed regarding the whole process and satisfied with the service as well as any complications that might be existed.

The patient data, a crucial document for both medical and official terms, has been developed and improved continuously by the department. Daily, about 250 informations are transferred from paper-pencil to electronic, computerised format for statistical purpose and further reference. Still, the department has to face the data problem in many aspects.

1. Daily, an abundant of information needs to be transferred to computer by non-medical personnel. This results in time consuming, data loss and piles of document.
2. Unclear peri-operative handwriting of medical or technical terms, particularly on copied files results in untrustworthy and disgraceful of patients' evidence.
3. Scanned files results in difficulties of data retrieval for assignments in research, education, administrative policy and finance. Consequently, a hospital becomes an unfaithful and treacherous organisation.

The investigators would like to develop an anaesthesia electronic medical record at the point of care. The objectives are to record peri-operative patients' information in a real-time fashion, manage all administrative tasks as annual reports, and operate data as search engine for research and educational purpose.