Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2022 Jul 2:79:104103.
doi: 10.1016/j.amsu.2022.104103. eCollection 2022 Jul.

Assessment of perioperative anesthesia record sheet completeness: A multi-center observational study

Moges Gelaw Taye  1 , Efrem Fenta  1 , Tadese Tamire  1 , Yewlsew Fentie  1
Affiliations

Assessment of perioperative anesthesia record sheet completeness: A multi-center observational study

Moges Gelaw Taye et al. Ann Med Surg (Lond). .

Abstract

Background: Anesthesia record is an essential part of perioperative patient management and, it is one of the global patient safety challenges. The aim of this study is to assess the completeness of perioperative anesthesia record sheets in Amhara regional state hospitals of Ethiopia.

Methods: A retrospective review of anesthetic records was employed for patients who underwent surgery in Amhara Regional State Hospitals of Ethiopia from December 1, 2019, to February 29, 2020. All the intraoperative, preoperative, and postoperative data completeness of anesthesia record sheets was assessed using a structured checklist.

Results: A total of 420 perioperative anesthetic records were included in this study. The basic preoperative history was documented in less than 80% of anesthesia record sheets. A physical examination was done and the results of the basic investigations were recorded in less than 75% of anesthesia record sheets. The name and dose of anesthetic medications were documented in 91% of the anesthesia records sheets. The completeness of parameters related to postoperative plans and orders was less than 70%.

Conclusion: The completeness of perioperative anesthesia record was poor in Amhara regional state hospitals of Ethiopia. Anesthesia professionals should document all the necessary perioperative parameters in the anesthesia record sheet.

Keywords: Anesthesia record completeness; DCSH, Dessie Comprehensive Specialized Hospital; DTCSH, Debre Tabor Comprehensive Specialized Hospital; ECG, Electro Cardiography; Ethiopia; FHCSH, Felege Hiwot Comprehensive Specialized Hospital; Perioperatively; WHO, World Health Organization.

PubMed Disclaimer

Conflict of interest statement

The authors have declared that no competing interests.

Similar articles

See all similar articles

Cited by

References

    1. A Z., H M., H G., B D., S M., Milkias M. Assessment of manual intraoperative anesthesia record-keeping practice at Dilla university. Open Access Surg. 2021;14
    1. Lodge W., Menon G., Kuchukhidze S., Jumbam D.T., Maongezi S., Alidina S., et al. Assessing completeness of patient medical records of surgical and obstetric patients in Northern Tanzania Assessing completeness of patient medical records of surgical and obstetric patients in Northern Tanzania. Glob. Health Action. 2020;13(1) [Internet] - PMC - PubMed
    1. Chekol W.B., Mersha A.T., Arefaynie N.R., Adem S. Improving the completeness of anaesthesia record charts for obstetric subarachnoid block among third year anaesthesia students in University of Gondar. Sri Lankan J. Anaesthesiol. 2020;28(2):137–142.
    1. Raymer K. The anesthetic record: how content and design influence function in anesthetic practice and beyond. J. Anesth. Clin. Res. 2011;4(2)
    1. Avidan A., Weissman C. Record completeness and data concordance in an anesthesia information management system using context-sensitive mandatory data-entry fields. Int. J. Med. Inf. 2012;81:173–181. 2012. - PubMed