Background:performance and quality indicators are essential tools in management and quality of medical units. Preanesthetic evaluation is a central component of clinical anaesthesia; however, anaesthetic records are not always sufficient or satisfactory. The goal of this study is to evaluate the technical-scientific care in
anaesthesiology consultation, based on standard 029/2013 (updated 24/04/2015) of Direção Geral de Saúde (DGS).1 Materials and Methods:descriptive retrospective analytical study. Assessment of preanesthetic evaluations records of adult patients proposed for elective surgery, from November 2016 to November 2017, taking into account the following indicators (based on DGS 029/2013 standard1 and the unit's protocol): registration rates in a specific anaesthetic form, complete clinical evaluation, complete objective examination, complete airway evaluation, calculated clinical risks and defined anaesthetic plan. Data was analysed using SPSS 24.0. Results and Discussion:653 consultations were evaluated (93% first consultations). 52.8% of the records were registered in a consultation diary and 46.2% in a specific
attached anaesthetic assessment form. Given the evaluation criteria, 32.8% of registries presented complete clinical evaluation, 82.5% complete objective examination, 55.6% complete airway evaluation and 76% defined anaesthetic plan; only 16.4% presented the calculated clinical risks (82.4% of consultations
without records of cardiac risk). Records in the specific form achieved better completion rates in clinical evaluation, physical examination, calculated clinical risks and defined anaesthetic plan (p<0.001).Conclusion:Specific anaesthetic assessment forms are useful tools to allow a systematic consultation process. They provide clear, concise and accessible data, improve the quality of information and minimize errors/record failures.Reference:1. Saúde, Direção Geral da. Avaliação Pré-Anestésica para Procedimentos Eletivos. s.l.:09/2013, 2013 (updated 24/04/2015).

01 / Qualitative analysis of medical records of preanesthetic evaluations