Peri-Operative Anaesthetic Documentation: A Report of Three Sequential Audits on the Quality of Outcomes, with an Insight Into Surrounding Legal Issues
| Autor: | Rajesh Sethi, Swati Sethi, William Brett Curtis, Thavarajah Visvanathan |
|---|---|
| Rok vydání: | 2018 |
| Předmět: |
Quality management
business.industry Medical record media_common.quotation_subject 030208 emergency & critical care medicine Audit Perioperative Surgical procedures medicine.disease 03 medical and health sciences 0302 clinical medicine Documentation 030202 anesthesiology medicine Original Article Quality (business) Medical emergency Anaesthetic record business media_common |
| Zdroj: | Turkish Journal of Anesthesia and Reanimation. :354-361 |
| ISSN: | 2149-276X |
| DOI: | 10.5152/tjar.2018.40222 |
| Popis: | 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. |
| Databáze: | OpenAIRE |
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