About the anesthesia record sheet and the writing of anesthesia medication orders

I have been an anesthesiologist for five or six years. If I were asked to write a complete record sheet, I still wouldn’t know. How many unqualified areas are there? The doctors in the department also have various writing habits in their records. This is also the case in some hospitals I know. Today, the hospital requires that used drugs for anesthetic drugs should be written down in temporary medical orders just like ward drugs. I suddenly had a question: Are there any unified standards for writing anesthesia medical documents? How to regulate it? Because of the particularity of the profession or that the profession is not taken seriously, many medical documents do not have requirements and examples for anesthesia documents. I will not go into the simple writing of blood pressure, heart rate, respiration, blood oxygen saturation, central venous pressure, arterial pressure, etc. There are instructions on the record sheet. I have read the "Notice on the Anesthesia Record Sheet of Medical Institutions in Henan Province" (Yuweiyi [2004] No. 8) before. It also introduces some formats and instructions for writing anesthesia records. For example, narcotic drugs use the symbol A, anesthesia-related drugs use O, liquids use F, and blood products use B symbol numbers. However, the introduction is still incomplete. For example, how should epidural medication, spinal anesthesia medication, nerve block medication, and local infiltration anesthesia medication be written? How to number? How to administer? (For example, for intravenous diazepam 10 mg, we can write A1 = diazepam injection 10 mg iv). Another question is whether the maintenance medications during general anesthesia need to be numbered. There are many more. It would be nice if there were examples for each anesthesia method in writing like cases.

There is also whether there are documented regulations for writing intraoperative anesthetic drugs in medical orders. The anesthesiologist is often both the orderer, executor and checker of medical orders. This results in the physician, executioner, and checker being all filled in by the same person. What's the point of such a doctor's advice? Is it still qualified? I hope that all anesthesiologists will take the initiative to unify and standardize our documents as soon as possible