NOVEMEBER 2026
Aim
To support safe, coordinated and accountable perioperative care by ensuring that every anaesthetic episode is documented contemporaneously, comprehensively and legibly.
Background
Members of the Victorian Perioperative Consultative Council (VPCC) regularly review medical records to identify opportunities to improve perioperative care. Whilst performing reviews, the VPCC Anaesthetic Subcommittee frequently finds anaesthetic charts that are incomplete, difficult to interpret, illegible or absent.
The anaesthetic chart is an essential part of the patient’s medical record. It supports immediate and future clinical care, communication between treating teams, audit, education, research, quality assurance, adverse event review and medico-legal investigation. To fulfil these functions, the record must clearly and accurately describe the care provided by the anaesthesia team.
The Australian and New Zealand College of Anaesthetists’ PG06(A) Guideline on the anaesthesia record outlines the information that should be documented across the perioperative episode. The guideline applies when general anaesthesia, sedation or regional blocks are administered and provides guidance on capturing critical and relevant clinical information.
The anaesthetic record should include:
- the patient’s identifiers and the procedure performed
- details of the pre-anaesthesia consultation and assessment
- the anaesthetic plan
- documentation of the consent discussion
- the anaesthetic technique, recorded in sufficient detail to allow the episode to be understood and, where appropriate, replicated
- physiological observations and monitoring
- intraoperative medications, fluids and blood products administered
- relevant clinical events, decisions, interventions and the patient’s response
The anaesthesia chart should be completed as care is delivered, or as soon as practicable afterwards, and must be clear, legible and readily accessible to clinicians involved in the patient’s ongoing care.
Electronic anaesthetic records carry the same documentation requirements as handwritten records. Anaesthetists and health services should ensure that electronic systems capture critical and relevant information consistently and that the available clinical output is complete, accessible and fit for purpose.
Recommendations
The Anaesthetic Subcommittee (ASC) of the Victorian Perioperative Consultative Council (VPCC) strongly recommends that anaesthetic documentation meet the standards described in ANZCA PG06(A). The documentation should contain sufficient detail for another clinician to reconstruct the care delivered, clinical events, decisions, interventions and outcomes.
If an adverse or unexpected event occurs, clinicians should make additional detailed and contemporaneous notes on the anaesthetic record or elsewhere in the patient’s medical record.
Anaesthesia departments and health services should have systems to ensure that anaesthetic records comply with ANZCA PG06(A) and that records are regularly audited against this standard.
References
ANZCA (Australian and New Zealand College of Anaesthetists) (2020a) PG06(A) Guideline on the anaesthesia record, ANZCA, accessed 4 November 2026.
ANZCA (Australian and New Zealand College of Anaesthetists) (2020b) PG06(A)BP Guideline on the anaesthesia record: background paper, ANZCA, accessed 4 November 2026.