Paper Chart

Paper Anaesthetic Chart

• Last resort when Cerner Anaesthesia is not possible [outside of Official Downtime] [During Official Downtime, follow Downtime/Uptime SOP]

• An Anaesthetic Note must be made on PowerChart indicating that a paper anaesthetic chart exists with basic pertinent information (e.g. type of anaesthetic, complications, etc).

• Please include any information about the conduct of anaesthesia that would be useful for a future anaesthetist (in case the paper anaesthetic chart is not scanned onto Mediviewer in a timely fashion or gets lost!)

• File the paper anaesthetic chart in the patient's pink folder to maximise the chance of it getting scanned to Mediviewer on patient discharge

• Specific forms (e.g. Difficult Airway) are available on Powerchart in the Ad Hoc - Anaesthesia folder

Drug chart

When a paper anaesthetic chart has been used, please ensure that you prescribe and sign that certain drugs were given intraoperatively on the Cerner Drug Chart

Key intraoperative drugs to be transcribed:

• Paracetamol

• Diclofenac

• Antiemetics

• Antibiotics

• Blood products

Please use clinical judgment for drugs not on this list.