Osswald P M, Hartung H J, Winter D, Bender H J, Lutz H
Anaesthesist. 1984 Sep;33(9):395-401.
It has long been recognised that it is necessary to document all medical actions. Every anaesthesia is to be documented on an anaesthetic transcript. Such a transcript has various purposes. It serves principally as an adequate patient-support, but also has administrative, statistical, scientific and forensic purposes. The transcript used at the Mannheim Klinikum is a printed form, which, apart from recording intra-operative events, also has room for entering pre- and post-operative test results. The recording of an anaesthetic transcript is an essential part of the duties of the anaesthetist in the clinic. Today, with the application of the most differentiated administrations of narcosis, it would seem that we can no longer do without a properly made anaesthetic transcript.
长期以来，人们一直认识到记录所有医疗行为是必要的。每次麻醉都要记录在麻醉记录单上。这样的记录单有多种用途。它主要作为充分的患者支持，同时也有行政、统计、科学和法医方面的用途。曼海姆临床医院使用的记录单是一种打印表格，除了记录术中事件外，还留有填写术前和术后检查结果的空间。在诊所中记录麻醉记录单是麻醉师职责的重要组成部分。如今，随着最精细的麻醉管理方法的应用，似乎没有一份制作得当的麻醉记录单我们就无法开展工作了。
