Efficacy of Multimodal Intervention Strategies in Improving Perioperative Documentation at a Rural Tertiary Care Centre

Abstract

Objective To assess the efficacy of intervention strategies in improving perioperative anaesthetic documentation. Methods This interventional study was conducted at our hospital over a period of 5 months, i.e. from October 2016 to February 2017. The subjects were anaesthetic consultants. The perioperative anaesthetic documentation of patients who received general anaesthesia was studied by retrospectively reviewing 100 patient charts before the application of intervention strategies. Intervention measures included lecture sessions, posters and handouts to highlight the important parameters to be documented. Later, another set of 100 patient charts of cases who received general anaesthesia from the same group of anaesthetic consultants were retrospectively reviewed. The recommendations of the Australia and New Zealand College of Anaesthetists were taken as the gold standard. A point-based scoring sheet was used for evaluation. Data were analysed using Microsoft Excel, and the statistical test used was the Mann–Whitney U Test. Results Documentation standards were significantly improved in the post intervention group compared to the pre intervention group. Furthermore, documentation scores were lower in emergency cases compared to elective cases in both groups. Conclusion Multimodal intervention strategies resulted in higher perioperative documentation scores, and scores were lower in emergency cases than in elective cases in both groups.

Factors affecting completeness of anaesthetic record: a cross-sectional study

“…This can be attributed to mandatory training and teaching sessions based on specific guidelines and criteria from the NHSO of Thailand. Research has supported the effectiveness of comprehensive training in improving both knowledge and attitudes towards completing medical records 15 , 17 , 18 . However, knowledge factors did not significantly correlate with the completeness of the medical records in this study.…”