Anaesthesia record keeping in an Australian metropolitan tertiary public teaching hospital

Background and Goal of Study:
The anaesthetic record is the only anaesthetic related record that documents the patient’s perioperative journey. The Australian and New Zealand College of Anaesthetists (ANZCA) has published a professional document detailing what should be recorded in an episode of anaesthetic care1. The aim of this project is to determine documentation compliance to college recommendations in an Australian tertiary hospital.

Materials and Methods:
Austin Health is a metropolitan tertiary public teaching hospital in Melbourne, Australia; it provides 980 beds across three campuses. Patients having surgery at Austin Health over a 7 day period were included in this audit. Austin Health’s anaesthetic records are paper based and require the anaesthetist to manually record all data. The patient’s anaesthetic records were retrospectively analysed. The primary outcome was the incidence of inadequately documented anaesthetic records according to the ANZCA recommendations. This project received ethical approval from the Austin Health Human Research Ethics Committee prior to data collection.

Results and Discussion:
During the period of 20th to 26th March 2017 inclusive, 588 patients underwent a procedure and 381 were included for this project. Overall, 17% (64/381) of the included charts followed the ANZCA recommended guidelines. 

Conclusion(s):
Overall, the number of charts compliant in all ANZCA recommendations was poor. Particularly important areas that were not completed include: planned or actual procedure, name or signature of anaesthetist, consent, airway assessment and airway device. Lack of adequate documentation in these areas could lead to patient morbidity and medico-legal issues; the completion rate should be 100%. This project should raise awareness for all hospital staff that anaesthetic documentation is important and can be improved on.

References:
1. Australian and New Zealand College of Anaesthetists. The Anaesthesia Record. Recommendations on the Recording of an Episode of Anaesthesia Care. PS06. Revised 2006. Accessed from: http://www.anzca.edu.au/documents/ps06-2006-the-anaesthesia-record-recommendations-o.pdf (last accessed 25/07/17)

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