Background: Anaesthetic record is an essential part of the patient's medical record. It includes the perioperative management that is relevant to the anaesthesia practice. This information helps other staff who will be involved in the care of the patient, for medico-legal defense and for quality assurance. We sometimes found anaesthetic recording sheets with incomplete information during the postoperative visit of patients in the recovery room and on the wards in our hospital. We aimed to assess the level of anaesthetic record completeness.
Methods:A cross-sectional study was conducted from February 18-March 18, 2013. All patients who were operated under anesthesia during the study period were included. A checklist developed based on our hospital anaesthetic sheet that used for data collection.Result: Hundred and twenty anaesthetic record sheets were audited. The name and time written consistently in local time were documented for all patients. The level of documentation was >90% for age, sex, date of operation, type of operation, medical history, physical examination, allergic history, medication history, consent, induction drugs with their dose, and maintenance drugs. However, the level of record completeness was < 50% for the content of consent, pre-induction vital signs, intraoperative vital signs, start and end of both anesthesia and surgery, type of regional anaesthesia, intraoperative blood loss, and order for postoperative management.
Conclusion and recommendation:The level of anaesthetic record completeness was substandard in our hospital compared with the recommendations of WFSA and AAGBI. Training should be given for anaesthetists about the relevance of appropriate documentation for perioperative patient care. Furthermore, We suggest that clinical audit need to be carried out regularly in this hospital until the anaesthetist meet the standards, and in other similar settings in the country to know the magnitude of the problem and to establish strategies that may improve the practice of clinical record keeping.