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

Abstract

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