An Audit of Anaesthesia Record-keeping at the Lagos University Teaching Hospital

Abstract

Background: The anaesthetic record documents how individual patients respond to surgery and anaesthesia. It is an essential part of patients’ medical records. We conducted an audit cycle of anaesthetic records to determine accuracy and completeness of records and any effects on record-keeping after feedback. Patients and Methods: All anaesthetic record charts filled for elective and emergency surgeries over a one month period were prospectively and anonymously scrutinised for completeness of records. A re-audit of 100 charts was performed after feedback of results to the department to determine any improvement in documentation. Results: One hundred anaesthetic charts were studied in each audit. 6% of anaesthetic charts were completely filled in both audits. The only variables to be recorded 100% in both audits were the patient’s name and type of airway device inserted in patients that had general anaesthesia. There was an improvement in records of all demographic data but only weight recorded a significant improvement from 31% to 47% (p=0.02). Preoperative clinical data that recorded significant improvement in the re-audit were Pre-operative history (51% to 91% p<0.0001), blood pressure (65% to 78% p=0.04), pulse rate (47% to 65% p=0.015), administration of premedication (30% to 63% p<0.001), and ASA score (60% to 78%, p=0.009). Significant improvement in pre-induction variables occurred in blood pressure (62% to 84% p=0.008) and pulse rate (67% to 85% p=0.004). Drug doses and timing of administration was the only intra-operative data which significantly improved from 81% to 94% (p=0.01). Conclusion: This ‘snap-shot’ sample showed poor standard of record-keeping in the initial audit. This may affect patient safety in future anaesthetics and lay the anaesthetist open to liability in the event of litigations. There was improvement in documentation in the re-audit after feedback of results to the department. A change in design of our anaesthetic charts avoiding repetitions as well as daily monitoring by the department may improve record keeping.

Keywords: Records, anaesthesia, data quality