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

Abstract

Background: Anaesthesia Information Management Systems (AIMS) are of critical importance for ensuring the comprehensive recording of anaesthesia data. This study aimed to investigate the factors influencing the completeness of anaesthetic records created by various healthcare professionals including anesthesiologists, nurse anaesthetists, residents/fellows, and anaesthetic nurse trainees. Methods: Employing an online Google Forms questionnaire, this descriptive research focused on understanding the factors contributing to the completeness of anaesthetic records. The survey was distributed to all anaesthesia personnel in the department, comprising a total of 165 participants. The questionnaire encompassed three primary aspects:(1) personal information, (2) knowledge related to recording anaesthetic records, and (3) concerns related to achieving high-quality record-keeping. To assess completeness, anaesthetic record forms were evaluated based on the 2020 Medical Record Audit Guideline of Thailand’s National Health Security Office, with a completeness rate exceeding 80% deemed acceptable. Spearman’s rank correlation was employed to analyze the connections between the associated factors and completeness of anaesthetic records. Results: From August to October 2021, 165 records were examined, indicating a completeness rate of 89.7%. Several factors exhibited significant correlations with the completeness of anaesthetic records. These included age (r = −0.223; P=0.004), job position (r = 0.44; P<0.001), years of anaesthesia experience (r = −0.208; P=0.007), experience in anaesthetic record training/teaching (r = 0.181; P=0.02), and attitude emphasizing high-quality record-keeping (r = 0.167; P=0.032). Conclusion: While personal attributes emerged as pivotal factors influencing record completeness, continuous training and a collaborative attitude were identified as critical for maintaining sustainability and achieving record-keeping goals.