Completeness of manual anaesthesia records in a tertiary facility in Nigeria

Ige, Olufemi; Adesina, Kikelomo T; Fatoba, Muyiwa A

doi:10.4103/jomt.jomt_1_17

Cited by 5 publications

(7 citation statements)

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“…Sub par documentation of manual record system has been documented in many previously conducted studies. 5,[7][8][9][10] Incomplete notes and abbreviations are a source of weak defense during litigations. Apart from that, information derived from record forms is of extreme value to subsequent practitioners who may give anesthesia services to the patient.…”

Section: Discussionmentioning

confidence: 99%

“…Similar high documentation rate has been recorded in studies conducted previously. [8][9][10] Although many studies have included postoperative orders in anesthesia form, in our center we record postoperative order in another form, hence was not included in this study.…”

Section: Discussionmentioning

confidence: 99%

“…Studies have shown that completion rate of intraoperative record form for emergency surgeries are poor. 1,10…”

Section: Discussionmentioning

confidence: 99%

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Manual Anesthesia Record Keeping at a Tertiary Care Center: A Descriptive Cross-sectional Study

et al. 2021

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Introduction: Intraoperative record form is one of the cardinal parts of anesthesia practices. Ideally, it should contain complete information about patients under anesthesia and intraoperative events. It serves as valuable information for subsequent patient management, research, or during medicolegal conditions. The objective of this study was to assess the practice and completeness of manual intraoperative anesthesia record keeping. Methods: A descriptive cross-sectional study was conducted from May 1 to July 31, 2021, in the postoperative ward of Kathmandu Medical College, which is a multispecialty tertiary care center. Approval from the ethical committee of Kathmandu Medical College Teaching Hospital was obtained (Reference: 2603202105) before conducting the study. Convenience sampling was used. The data were entered in Microsoft Excel and statistical analysis was done using Statistical Package for the Social Sciences version 20. Point estimate was done at 95% Confidence Interval and data present in numbers and percentages. We devised forty-two variables, which included demographics, personal identifiers, intraoperative events, anesthesia and airway management, intraoperative parameters, monitoring and medication. Results: The overall completion rate was 202 (52.59%) (47.6-57.57 at 95% Confidence Interval). Out of 42 variables, the completion rate of 14 variables was less than 50%. Among those were important parameters such as known allergies 94 (24.4%), Body mass index 50 (13%), intraoperative saturation of oxygen 104 (27%), intraoperative electrocardiogram recording 107 (27.8%), total fluid volume administered 45 (11.7%), patient status on transfer 84 (21.8%) had poor completion rate. Conclusions: Our intraoperative record form shows poor completion rate, which was similar to other studies. many important variables were missing and had incomplete data.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Manual Anesthesia Record Keeping at a Tertiary Care Center: A Descriptive Cross-sectional Study

et al. 2021

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“…for obstetric manual anaesthesia records. [14] These findings are understandable as the focus of clinicians is more on resuscitation and maintenance of patient's clinical condition with data completeness taking a back seat. Greater education and emphasis is required to improve completion rates in this population.…”

Section: Discussionmentioning

confidence: 99%

Completeness of manual data recording in the anaesthesia information management system: A retrospective audit of 1000 neurosurgical cases

et al. 2019

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Background and Aims:Anaesthesia information management system (AIMS) is increasingly implemented in many hospitals. Considering the capital cost involved in its installation and maintenance, it is important to evaluate its performance and adoptability by end users. This study assessed the completeness of manual data recording in the AIMS one year after its implementation and also evaluated potential predictors for completeness.Methods:In this retrospective audit of AIMS, 1000 electronic anaesthesia records of patients undergoing neurosurgical procedures over one year were assessed for completeness of 41 preidentified items, one year after its implementation. Parameters evaluated were patient identifiers, personnel identifiers, demographics, airway management parameters, anaesthesia management items and end-of-anaesthesia parameters. We hypothesised that completeness of anaesthesia record can be predicted by nature of surgeries, case sequence, seniority of anaesthesiologist and phase ( first or second) of the study period.Results:We observed higher completeness of manual data recording during phase 2 of AIMS use compared to phase 1. Higher grade of anaesthesiologist, second case of the day and emergency surgery led to reduction in completeness of data entry. Anaesthesiologist grade significantly predicted complete entry of 18 (44%) variables, case number predicted 8 (20%) variables and phase- and procedure-type predicted 6 (15%) and 5 (12%) variables, respectively.Conclusion:Completeness of manual data recording in the electronic AIMS is poor after one year of implementation. First case of the day, second phase of study period, elective cases and trainee anaesthesiologist are associated with better completeness of manual data recording in the AIMS.

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“…Semi-structured questionnaires from the anaesthesia record format which adopted from previous study 4 , and chart review used to collect the data. To review these tools, checklist was developed based on a combination of criteria outlined by the American society of anesthesiologists (ASA),Australian and New Zealand College of Anaesthetists (ANZCA) 11 , and directly changed into question forms with three integral checking components: “Yes,” “No,” and “incomplete”.…”

Section: Methodsmentioning

confidence: 99%

Simulation-based perioperative anaesthesia information management practice: cross-sectional study

Admassie,

Ferede,

Mekonnen

et al. 2023

Annals of Medicine &Amp; Surgery

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Background: Perioperative anaesthesia record completeness is very essential skill of the anaesthesia profession at the time of operation in the health setting. During perioperative, anaesthesia care sometimes there may be missing important information of the patient, medication taken or planned. This study aimed to improve perioperative anaesthesia information management practice. Methodology: Pre-interventional and post-interventional cross-sectional study was conducted from 21 June to 25 July 2022 on 164 anaesthesia record filled by 51 anaesthesia care provider in pre-interventional and post-interventional phase. Data were collected using a semi-structured questionnaire and the data entered by Epi-data software (version 4.6) and analyzed by using SPSS version 26. For all indicators, the projected completion rate was 100%. Indicators with completion rates of greater than 90% were classified as acceptable, while those with completion rates of 50% were seen as urgently needing improvement. Results: Pre-interventional result: among all indicators, none of the indicators had 100%, completeness rate. Postoperative nausea and vomiting management orders, the names of the surgeon and anaesthetist, the location of the intravenous cannula, the maintenance of anaesthesia, the total amount of fluid supplied, the content of the consent discussion, and null per ose status, age, and weight of the patient were some of the markers that were identified below average (50%) and in need of significant improvement. Post-interventional result: when compared with the pre-interventional result, their documentation skills were improving after discussions with stakeholders and the relevant bodies; however, none of the indicators attained 100% completion rate. Conclusion and recommendation: Even after the interventions, the desired completion rate was not attained. As a result, it requires ongoing instruction on perioperative anaesthesia information management according to the standard perspectives.

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Completeness of manual anaesthesia records in a tertiary facility in Nigeria

Cited by 5 publications

References 0 publications

Manual Anesthesia Record Keeping at a Tertiary Care Center: A Descriptive Cross-sectional Study

Manual Anesthesia Record Keeping at a Tertiary Care Center: A Descriptive Cross-sectional Study

Completeness of manual data recording in the anaesthesia information management system: A retrospective audit of 1000 neurosurgical cases

Simulation-based perioperative anaesthesia information management practice: cross-sectional study

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