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Domain A: knowledge, skills and performance<br />

Attribute 3: keep clear, accurate and legible records<br />

Explanatory notes<br />

The basic premise for keeping good quality medical records in anaesthesia, pain medicine and intensive<br />

care is to facilitate communication amongst colleagues, and ensure the effective and safe continuation<br />

of care of patients at different times and by different team members. It is therefore particularly<br />

important that critical incidents, complications and unexpected events are accurately documented.<br />

A secondary, but important, premise is that records (provided patients have been informed and they<br />

do not object) are an important resource when it comes to auditing areas of anaesthesia care and<br />

reviewing cases for educational purposes.<br />

Related guidelines and sources of information<br />

The Association of Anaesthetists of Great Britain and Ireland<br />

››<br />

Information management: guidance for anaesthetists, 2008.<br />

Prepared by the Joint Committee on Good Practice | Page 13

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