Audit on documentation completeness after regional nerve blocks at University of Gondar referral hospital, 2018

Abstract

Practices of regional nerve block here in Gondar University Referral Hospital are expanding with multiple techniques and different approaches with increasing availability of equipments and medications. The demands of documentation of regional nerve block are growing well ,however there are no specified protocols which should be recorded for each individual nerve block, no separate record

The Current Practice of Spinal Anesthesia in Anesthetists at a Comprehensive Specialized Hospital: A Single Center Observational Study

“…35 Another study conducted at the University of Gondar by Chekol W et al, 2018 found as all anesthetists did not wash their hands and wear sterile gowns throughout the procedure which is inline with our study. 36 In conflicting with our finding's various literature and clinical practice guidelines reported and recommended that while performing this spinal nerve block, it is vital to completely practice the standards of spinal anesthesia to ensure patient safety and enhance the better outcome. 23,24,37…”

“…Another study conducted at the University of Gondar by Chekol W et al, 2018 found as all anesthetists did not wash their hands and wear sterile gowns throughout the procedure which is inline with our study. 36 …”

Improving the completeness of anaesthesia record charts for obstetric subarachnoid block among third year anaesthesia students in University of Gondar

“…However if there is lack of adequate perioperative documentation, it will hinder the quality and safety of patient management, lead to legal implications and difficulty in getting briefed information during handover period. 4,5,15,16 Also adequate documentation of perioperative anaesthetic events will be valuable to subsequent anaesthetists who required to provide anaesthetic services to a patient for the future. 15,17,18 Conclusions This audit identified that there were significant improvements of post intervention documentation.…”

“…[1][2][3] Documenting and keeping readily accessible records are responsibilities of anaesthesia practitioners and anaesthetists. [4][5][6] The anaesthetic record has become a key element of good anaesthetic practices, which is helpful for other staff who will be involved in the management of the patients. It will safeguard against medico legal issues, facilitate effective monitoring of patients and is an important tool for research and audit and quality improvement in anaesthesia.…”

“…It allows for appropriate management of perioperative anaesthesia, is useful to improve patient's recall of risks and benefits and to get briefed information during hand over of operated patients and to request written rather than verbal communication. 4,7,8 Poor habit of documentation will lead to legal implications, high mortality and morbidity rate, poor patient management and safety and poor coherence of patient's approach. All of these functions depend on the completeness of the record and on the relevance and comprehensiveness of the data recorded.…”