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

Berhe, Yophtahe Woldegerima; Kemal, Semira

doi:10.1016/j.ijso.2018.10.006

Cited by 10 publications

(30 citation statements)

References 39 publications

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“…The findings are in line with the study conducted by Marco AP et al which shows the completion rate was higher in the group with structured form when non structured and structured forms for preanesthetic evaluation were compared [7]. The study by Woldegerima and et al indicated that the elective procedure with most of the indicators is higher in the elective surgery compared with emergency surgery [17]. In our study, the complete rate was more in the elective surgery compared to emergency surgery.…”

Section: Dicussionsupporting

confidence: 92%

Clinical Audit on the Practice of Documentation at Pre-Anesthetic Evaluation in Teaching Institut

Karnalka¹,

Andhal²,

Khedeka³

2023

PIJR

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Introduction: The preanesthetic evaluation, documenting it and maintaining the record is the responsibility of anesthetist. Better documentation practices can improve the patient's outcome. It has the pivotal role in medicolegal aspects. However, the documentation is one of the challenges when it comes to quality of care. The objective of the study was to assess the practice of documentation at preanesthetic evaluation and completeness of Preanesthetic evaluation tools. Method: The descriptive study was conducted in tertiary care hospital. Modied global quality index (GQI) is used to prepare the Predefined twenty-two indicators.The data analysis is done using SPSS version-20.Result: A total of 300 pre-anesthetic evaluation tools (PAETs) were reviewed. There was different trend in terms of completion rate for elective and emergency cases. However, there was no PAETs found complete. Indicators with high completion rate (>90%) were signed a consent, past medical history (PMH), history of medication, allergy, surgical procedure, cardiovascular examination, airway examination and respiratory examination. Anesthetic plan, premedication, vital signs, a name, per-oral status and age were found with below average (<50%) completion rate. Conclusion and recommendations: Documentation during the preanesthetic visit observed below the standard. Which need to be standardized for uniformity. Use of electronic system with prefilled formats and training of personnel involved in the process is the way forwar

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Section: Dicussionsupporting

confidence: 92%

Clinical Audit on the Practice of Documentation at Pre-Anesthetic Evaluation in Teaching Institut

Karnalka¹,

Andhal²,

Khedeka³

2023

PIJR

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“…Nevertheless, all the professional anesthesia bodies worldwide strongly emphasize that PAR documentation must be adequate and complete as it is important for patient safety, quality assurance and medico-legal purposes. [7][8][9][10][11][12][13][14][15][16] We chose the 'ASA Statement on Documentation of Anesthesia Care' as the standard guideline for comparison with our PAR because its' policy update was more recent as compared to the ANZCA guideline. 8,9 There was a study done previously in an Australian teaching hospital that compared the adequacy of perioperative anesthetic documentation and its' adherence to the Australian guidelines, and found it to be unsatisfactory.…”

Section: Discussionmentioning

confidence: 99%

Assessing the completeness of perioperative anesthetic record documentation in a tertiary hospital

Bolhan

Yahya

Izaham

et al. 2020

APIC

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Background and Objective: Many previous studies assessing the completeness of perioperative documentation of surgical patients were reported to be inadequate and unsatisfactory. The aim of this study was to compare the perioperative anesthetic record (PAR) at our tertiary care institution to a standard guideline and have an audit of its completeness. Methodology: It was a prospective, observational study, done in the general operating theater of Universiti Kebangsaan Malaysia Medical Centre (UKMMC). We compared our PAR to the American Society of Anesthesiologists (ASA) policy statement on documentation of anesthesia care. We audited the completeness of PAR documentation of 358 patients by using a self-generated checklist which was created in accordance to the PAR parameters. A total of 44 parameters were studied covering three phases; preoperative, peroperative and post-operative phases. Results: Although the UKMMC PAR varied from the ASA guidelines, various salient parameters were identical in both. None of the perioperative forms were completely filled throughout the three perioperative phases. Out of 44 parameters studied, only 2 parameters were completely filled, which were medications administered and fluid therapy. Conclusion: Parameters given in the UKMMC PAR varied with the ASA guidelines and the documentation was found to be only partially complete. Hence, necessary modification of the current PAR in our institution, and the stress on filling it completely is needed to improve the quality of perioperative anesthetic documentation. Keywords: Audit; Completeness; Perioperative; Anesthetic record; Documentation Citation: Bolhan HA, Yahya N, Izaham A, Mat WRW, Rahman RA, Musthafa QA. Anaesth. pain intensive care 2020;24(6):--- Received: 23 April 2020, Reviewed: 17 August 2020, Revised: 18 October 2020, Accepted: 27 October 2020

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“…A similar high (92.6%) documentation rate has been reported. 23 Allergic drug reaction accounts for 1:10,000-20,000 in anesthesia, common causative agents include neuromuscular blocking agents, antibiotics and latex. 24 Questioning regarding the last oral intake is a compulsory component of preoperative assessment.…”

Section: Figure 1: Overall Paaf Completion Ratementioning

confidence: 99%

“…This is contrary to previous studies where a very low rate of fasting status was reported. 22,23 This difference could be due to the format of our PAAF where fasting status is written immediately beside the final clearance. This makes documentation of fasting status easy but despite this, competition is less than the acceptable target of our study.…”

Section: Figure 1: Overall Paaf Completion Ratementioning

confidence: 99%

Clinical audit on quality of preanesthesia evaluation

Shahzad¹,

Younas²,

Khan³

2021

APIC

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Background: Preoperative evaluation (PAE) gives in-depth view of patient’s clinical condition and helps match mode of anesthesia accordingly. This study was planned to assess the quality of documentation in pre-anesthesia assessment form (PAAF) completed during preoperative assessment. Methodology: This descriptive study was conducted at Pakistan Kidney and Liver Institute and Research Center (PKLI & RC) Lahore. Pre-Anesthesia assessment forms of patients operated from 1st January to 31st December 2019 were reviewed. A 22-components modified Global Quality Index (GQI) was used to assess the quality of PAAF. Descriptive statistical analysis was performed using SPSS version 25. Results: Completion was excellent (100 %) in only one indicator; eighteen indicators had an acceptable completion rate (90-99 %) while three indicators were completed in < 90 % PAAF. Consent was the only component complete in 100% PAAF. Documentation of age (25%), past medical history (89.4%) and fasting status (88.4%) were the least documented aspects of PAAF. The average completion rate was 93.5 ± 5.2 % and all 22 indicators of GQI were completed in 14.3% PAAF. Conclusion: Our audit shows that majority of PAAF are complete and all its components have been well documented. Only few elements were not recorded in some PAAS. Further education and audit will be required to achieve complete documentation. Key words: Preanesthesia assessment; Preoperative evaluation; Documentation; Global Quality Index Citation: Shahzad S, Younas T, Khan EUD. Clinical audit on quality of preanesthesia evaluation. Anaesth. pain intensive care 2021;25(1):15-18; DOI: 10.35975/apic.v25i1.1429 Received: 31 October 2020, Reviewed: 22 December 2020, Accepted: 23 December 2020

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

Cited by 10 publications

References 39 publications

Clinical Audit on the Practice of Documentation at Pre-Anesthetic Evaluation in Teaching Institut

Clinical Audit on the Practice of Documentation at Pre-Anesthetic Evaluation in Teaching Institut

Assessing the completeness of perioperative anesthetic record documentation in a tertiary hospital

Clinical audit on quality of preanesthesia evaluation

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