Congruency Between Planned and Performed Procedures and Adherence to Recommended Perioperative Practices: A Chart Audit of High‐Risk Surgical Patients

Abstract

Documentation in an electronic health record system helps ensure that perioperative personnel provide appropriate treatment and care to surgical patients. A retrospective chart review performed with an audit instrument sought to describe the extent to which the documented preoperative plan for a surgery corresponded to the procedure performed. The secondary aim was to describe to what extent perioperative nurses' and physicians' documented care was in accordance with national and international guidelines. Extracted data consisted of physicians' and nurses' documentation of 24 high-risk surgical patients who died within 30 days after a procedure at two hospitals in a single health system. Surgeons documented a planned surgical method for 23 of the 24 patients and the surgical team performed 20 surgeries as planned. Perioperative nurses' and anesthesia professionals' documentation showed a lack of adherence to recommended practices: compliance with guidelines concerning antibiotic prophylaxis and preoperative hygiene preparation were low.