Record Keeping by Anaesthetist in a Developing Country

Abstract

Background: Record keeping is important in every organization, especially in health facilities. It gives information about the course of treatment and progress of disease. Data from records can be used for research, audit and to improve healthcare.
Methodology: The study was conducted in four theatres of the University of Port Harcourt Teaching Hospital Theatres: orthopaedic, labour ward, ear nose and throat and oral maxillofacial surgery Theatres. This is a forty month retrospective study from January, 2008 to April, 2011. The physician anaesthetics' theatre register and the perioperative nurses' theatre register were compared.
Results: During the study period 5069 cases were recorded by the nurses and 3227 by the physician anaesthetist in the theatres studied. The nurses recorded 548 in the orthopaedic theatre, 4181 in labour ward theatre, 84 in oral maxillofacial surgery theatre and 256 in the ear nose throat theatre. The anaesthetist recorded 200 in the orthopaedic theatre, 2842 in the labour ward theatre, 58 in the oral maxillofacial surgery theatre and
127 in the ear nose throat theatre. The difference between the perioperative nurses and physician anaesthetist theatre registers was 348(63.50%) in orthopaedic theatre, 129 (50.39) in ear nose throat theatre, 1339(32.03%) in the labour ward theatre and 26 (30.95%) in the oral maxillofacial surgery theatre.
Conclusion: Physician anaesthetists are not keeping complete records. Record keeping should be emphasized in the training of anaesthetists.

Keywords: Record keeping, anaesthetist, developing country.