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. 2018 Sep;46(5):354-361.
doi: 10.5152/TJAR.2018.40222. Epub 2018 Sep 4.

Peri-Operative Anaesthetic Documentation: A Report of Three Sequential Audits on the Quality of Outcomes, with an Insight Into Surrounding Legal Issues

William Brett Curtis  1 , Rajesh Sethi  2 , Thavarajah Visvanathan  2 , Swati Sethi  2
Affiliations

Peri-Operative Anaesthetic Documentation: A Report of Three Sequential Audits on the Quality of Outcomes, with an Insight Into Surrounding Legal Issues

William Brett Curtis et al. Turk J Anaesthesiol Reanim. 2018 Sep.

Abstract

Objective: The aim of the audits was to assess contemporary performance, with comparison of the same against previous outcomes, to gauge trends in clinical practice. This allowed for completion of the audit cycle, as well as the ability to analyse and consistently improve the quality of care delivered to our patients.

Methods: We undertook three prospective audits on the quality of peri-operative anaesthetic documentation in the years 2009, 2011 and 2014, respectively. Anaesthetic records for patients undergoing elective as well as emergency surgical procedures were assessed for 'adequacy of peri-operative documentation' based on a combination of select criteria outlined by the Royal College of Anaesthetists and the Australian and New Zealand College of Anaesthetists.

Results: A total of 1000 anaesthetic records were analysed in 2009, followed by a review of 412 records and 376 documents in 2011 and 2014 respectively. In the year 2014, 43.8% of pre-operative anaesthetic records were 'appropriately' documented. This was in stark comparison to 16.3% and 25.9% in the years 2009 and 2011, respectively. The quantity of 'adequately' documented intra-operative records increased to 35.1% in 2014, in comparison to 25.5% and 22.7% in 2009 and 2011, respectively. There was an overall improvement in the standards of peri-operative documentation in consecutive audits.

Conclusion: We propose that regular audits on 'anaesthetic record keeping' can lead to an improvement in the standards of this often overlooked, but essential scope of our practice.

Keywords: Medical records; documentation; electronic record; quality improvement.

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Conflict of interest statement

Conflict of Interest: The authors have no conflicts of interest to declare.

Figures

Figure 1. a, b
Figure 1. a, b
(a) Pre-operative information collected. (b) Pre-operative information assessed for ‘adequacy of documentation’
Figure 2. a, b
Figure 2. a, b
(a) Intra-operative information collected. (b) Intra-operative information assessed for ‘adequacy of documentation’
Figure 3
Figure 3
Proportion of pre-operative information adequately documented
Figure 4
Figure 4
Trend of adequately documented pre-operative anaesthetic records
Figure 5
Figure 5
Proportion of intra-operative information adequately documented
Figure 6
Figure 6
Trend of appropriately documented intra-operative anaesthetic records
See this image and copyright information in PMC

References

    1. Kadry B, Feaster WW, Macario A, Ehrenfeld JM. Anaesthesia information management systems: past, present and future of anaesthesia records. Mt Sinai J Med. 2012;79:154–65. doi: 10.1002/msj.21281. - DOI - PubMed
    1. Raff M, James MFM. An audit of anaesthetic record keeping. South African Journal of Anaesthesia and Analgesia. 2003;9:7–9. doi: 10.1080/22201173.2003.10873005. - DOI
    1. Falcon D, Francois P, Jaquot C, Payen JF. Evaluating the quality of the anaesthetic records. Annales Françaises d’Anesthésie et de Réanimation. 1999;18:360–7. doi: 10.1016/S0750-7658(99)80063-X. - DOI - PubMed
    1. Elhalawani I, Jenkins S, Newman N. Perioperative anaesthetic documentation: Adherence to current Australian guidelines. J Anaesthesiol Clin Pharmacol. 2013;29:211–5. doi: 10.4103/0970-9185.111726. - DOI - PMC - PubMed
    1. Bowers R, Booth D. Anaesthetic record keeping. In: Colvin J, Peden C, editors. Raising the standard: a compendium of audit recipes. 3rd edition. RCOA; 2012. pp. 94–5.

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