Improved difficult airway documentation using structured notes in Anesthesia Information Management Systems

  • Clyde MatavaEmail author
  • Monica Caldeira-Kulbakas
  • Jesse Chisholm

To the Editor,

Difficult airway management remains a challenge and each encounter requires accurate and quality documentation.1 Failure to document difficult airway may threaten patient safety during subsequent encounters. Complete documentation enables subsequent healthcare providers to plan approaches that avoid and minimize morbidity and mortality.2 Our institution recently transitioned from a paper anesthesia record system to an Anesthesia Information Management System (AIMS) as part of the enterprise electronic medical record solution, Epic (Epic Systems Corporation, Epic Anesthesia Module, Verona, WI, USA).

During the transition from paper to the AIMS record, we elected to use the structured format for a difficult airway note provided by the vendor. Our goal was to determine if note quality and completeness improved with the use of the AIMS structured difficult airway note compared with paper records. Approval was obtained (December 13, 2018) from our institutional quality and...


Conflict of interest


Funding statement


Editorial responsibility

This submission was handled by Dr. Hilary P. Grocott, Editor-in-Chief, Canadian Journal of Anesthesia.


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Copyright information

© Canadian Anesthesiologists' Society 2019

Authors and Affiliations

  1. 1.Department of Anesthesia and Pain MedicineThe Hospital for Sick ChildrenTorontoCanada
  2. 2.Department of Anesthesia, Faculty of MedicineUniversity of TorontoTorontoCanada

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