Clinical audit on the practice of documentation at preanesthetic evaluation in a specialized university hospital

Introduction: Performing preanesthetic evaluation, documenting and keeping readily accessible record are responsibilities of anesthetists. Documentation can improve overall patient outcome. It also has an irreplaceable role in medico-legal aspects. Documentation is one of the challenges in providing quality care. The objective of the study was to evaluate documentation practice during preanesthetic visits. Method: A descriptive study was conducted in a university hospital. Predefined twenty-two indicators were prepared according to modified global quality index (GQI). SPSS version-20 was used for analysis. Results: A total of 122 pre-anesthetic evaluation tools (PAETs) were reviewed. None of PAETs found fully completed according to the indicators. Trends differ between elective and emergency conditions. Indicators with high completion rate (>90%) were signed a consent, past medical history (PMH), history of medication, allergy, anesthesia and surgery, cardiopulmonary examination, airway examination, pre-operative diagnosis and planned procedure. Anesthetic plan, vital signs, a name, per-oral status, premedication, and age were found with below average (<50%) completion rate. Conclusion and recommendations: Documentation practice during the pre-anesthetic visit was below the standard. Unclear instructions should be replaced with standardized contents. Providing regular trainings on clinical documentation for students and staffs, and introducing modern electronic-based documentation system may improve the practice. (C) 2018 The Authors. Published by Elsevier Ltd on behalf of Surgical Associates Ltd.