Gibbs R F
Brigham and Women's Hospital, Boston, MA 02115.
J Clin Monit. 1989 Oct;5(4):251-5. doi: 10.1007/BF01618257.
The anesthesia record is often crucial to successful defense in a meritless claim, because the adversarial role of the plaintiff's medical expert witness requires an attack on the record. Likewise the record may be pivotal in determining whether a defense should even be mounted as an alternative to an early settlement, because the failure of meaningful, supportive, or exculpatory documentation raises serious questions about the quality of care rendered. Advancing technology has made possible revolutionary changes in real-time monitoring and data recording. Concepts favoring the development and adoption of automated record systems for anesthesia are outlined through historic medicolegal perspectives on record keeping in general and computerization of the monitoring and recording methods in specific as a means of providing the best medicolegal evidence in defense of the anesthesiologist's performance. The analogy is often made between the successful development and acceptance of the flight data recorder and cockpit voice recorder combination in aviation and ongoing software development for automated recordkeeping and the quest for its use and professional acceptance in both anesthesia and intensive care settings.
麻醉记录对于在毫无根据的索赔中成功辩护往往至关重要，因为原告医学专家证人的对抗角色要求对记录进行攻击。同样，记录对于确定是否甚至应进行辩护以替代早期和解可能至关重要，因为缺乏有意义、支持性或开脱罪责的文件会引发对所提供护理质量的严重质疑。技术进步使得实时监测和数据记录发生了革命性变化。通过对一般记录保存以及特定监测和记录方法计算机化的历史法医学观点，概述了支持开发和采用麻醉自动记录系统的概念，作为在为麻醉医生的表现辩护时提供最佳法医学证据的一种手段。人们常常将航空领域飞行数据记录器和驾驶舱语音记录器组合的成功开发和接受，与正在进行的用于自动记录保存的软件开发以及在麻醉和重症监护环境中对其使用和专业认可的追求相类比。
