|Year : 2017 | Volume
| Issue : 2 | Page : 86-89
Completeness of manual anaesthesia records in a tertiary facility in Nigeria
Olufemi A Ige1, Kikelomo T Adesina2, Muyiwa A Fatoba3
1 Department of Anaesthesia, University of Ilorin; Department of Anaesthesia, University of Ilorin Teaching Hospital, Ilorin, Nigeria
2 Department of Obstetrics and Gynaecology, University of Ilorin; Department of Obstetrics and Gynaecology, University of Ilorin Teaching Hospital, Ilorin, Nigeria
3 Department of Anaesthesia, University of Ilorin Teaching Hospital, Ilorin, Nigeria
|Date of Web Publication||15-Nov-2017|
Olufemi A Ige
Department of Anaesthesia, University of Ilorin, Ilorin
Source of Support: None, Conflict of Interest: None
Introduction: The human brain, as efficient as it is, cannot remember everything. It is legally required by law that healthcare providers maintain a record for each of their patients. In anaesthesia, every aspect of the anaesthetic care from preoperative to postoperative care needs to be documented. It is, therefore, essential to review the efficiency of manual record keeping and explore possible ways of improving it.
Materials and Methods: This was a retrospective study of all patients of obstetrics undergoing caesarean section between 1st July, 2013 and 30th June, 2014. Study participants were identified from Institutional Anaesthesia record books and clinical record (case notes). With the aid of a questionnaire, relevant information concerning patients’ biodata, names of health personnel involved in the surgery and clinical information about vital signs and drug administration were documented from the records.
Results: The chart completion rate was 63.88%. Emergency procedures had an average chart completion rate of 51.68% while the charts in elective procedures had a completion rate of 73.4%. The patients’ name was the most frequently recorded item. The Apgar score was not recorded in any of the charts reviewed. Critical incidents were poorly charted with a chart completion rate of 36.59%.
Conclusion: Manual recording of anaesthesia information is unreliable and results in incomplete anaesthesia records. It is poorer in emergency surgeries as compared to elective ones. A comprehensive approach that would include structured teaching on the importance of chart completion and the use of automated information systems in recording may correct this anomaly.
Keywords: Anaesthesia, chart, intraoperative, manual records
|How to cite this article:|
Ige OA, Adesina KT, Fatoba MA. Completeness of manual anaesthesia records in a tertiary facility in Nigeria. J Med Trop 2017;19:86-9
| Introduction|| |
The human brain, as efficient as it is, cannot remember everything. Patient information often need to be recalled in precise detail for further patient care, research, quality assurance and for medicolegal reasons. When physicians attend to patients, record keeping becomes necessary to ensure that vital aspects of that interaction are not lost.
It is legally required by law that healthcare providers maintain a record for each of their patients. The records may be handwritten, typed or electronic. Regardless of its form it must be complete and accurate.
In anaesthesia, every aspect of the anaesthetic care from preoperative to postoperative care needs to be documented. Anaesthesia records can be manual or automated. Automated records have been found to be more accurate than manual records. Manual record keeping has been shown to be incomplete and often fell short of the minimum acceptable standard. Manual record keeping has also been found to remove clinically important data from the records.
Despite the fact that some studies have found electronically generated anaesthesia records to be more representative of the true state of the patients, many hospitals have not adopted electronic records keeping. In one study, 4% of physicians in the United States reported having an extensive, fully functional electronic-records system, and 13% reported having a basic system. The barriers to the adoption of electronic records keeping include financial, technical, time, psychological, social, legal, organizational and change process.
It is, therefore, essential to review the efficiency of manual record keeping and explore possible ways of improving it.
| Materials and methods|| |
The study was conducted at the University of Ilorin Teaching Hospital, Ilorin, Nigeria. This hospital is a referral centre for patients from Kwara State and neighbouring states of Kogi, Niger, Ekiti and Oyo. It has a main theatre complex and an obstetric unit housed in a two-storey building standing separate from the main theatre complex. The study was conducted in the Obstetric Unit.
The records of all patients of obstetrics who had caesarean section performed under general or regional anaesthesia during the study period were retrieved and analysed.
This was a retrospective study of all patients of obstetrics undergoing caesarean section between 1st July, 2013 and 30th June, 2014. Study participants were identified from Institutional Anaesthesia record books and clinical record (case notes). The case notes and anaesthesia intra-operative records’ charts were retrieved from the records department. With the aid of a questionnaire, relevant information concerning patients’ biodata, names of health personnel involved in the surgery and clinical information about vital signs and drug administration were documented from the records.
All patients anaesthetised from July 2013 to June 2014 were included.
All patients who had caesarean section under general or regional anaesthesia during the study period were recruited into the study. There were no exclusion criteria.
Ethical permission was obtained from the Ethical Review Board of the University of Ilorin Teaching Hospital.
After approval by the Hospital Ethics Committee, the hospital records of all patients that fulfilled the criteria were reviewed and relevant information retrieved using a questionnaire which included the patients’ demographic information, identity of health care providers, preoperative, intraoperative and postoperative information, anaesthetic technique, birth information and critical incidents.
Chart completion rate
The number of times each column on the anaesthesia chart was filled by the anaesthetist was noted, and a completion rate was calculated and expressed in percentage for each column.
The chart completion rate represented the average of all the completion rates calculated for all the charts studied.
Statistical analysis was performed using the Statistical Package for the Social Sciences version 17.0 software for Windows (SPSS Inc., Chicago, IL, USA). Categorical data were presented as absolute values (%). Continuous data were presented as median and range. A P-value of <0.05 was considered statistically significant.
| Results|| |
A total of 806 out of 845 records were studied representing a retrieval rate of 95.4%. Emergency caesarean section accounted for 724 (89.8%) of the operations while 82 (10.2%) were elective procedures.
No item on the anaesthesia chart was recorded in every chart studied. The chart completion rate was 63.88%. Emergency procedures had an average chart completion rate of 51.68% while the charts in elective procedures had a completion rate of 73.4% (P = 0.038). This was statistically significant [Table 1].
The column for the patients’ name was recorded in 802 (99.5%) charts. It was the most frequently recorded column. This was followed by the patients’ gender, name of the anaesthetist and date of procedure which were recorded in 793 (98.39%), 791 (98.14%) and 790 (98.02%) charts, respectively. Other items recorded were surgeon’s name in 778 (96.53%) charts, hospital number in 773 (95.91%) charts, age of patient in 769 (95.41%) charts and hospital ward in 713 (88.46%) charts. The patients’ weight was not recorded in any of the charts reviewed. The average rate of documentation of demographic information was 85.60%.
In preoperative information, the preoperative condition of the patient was the most frequently recorded column. It was recorded in 704 (87.35%) charts. Other items recorded were time of patients’ last meal, premedication administered and preoperative investigations which were recorded in 503 (62.41%), 91 (11.29%) 56 (6.95%) charts, respectively. The average rate of completion for preoperative information was 42.0%.
The vital signs consisting of blood pressure and pulse rate were documented in 475 (58.93%) charts while surgical information about the diagnosis and proposed operation was documented in 775 (95.69%) charts. Information on administered drugs and intravenous fluids was documented in 636 (78.95%) charts while information on anaesthesia technique was documented in 560 (69.45%) charts. The average rate of completion of intra-operative information was 75.76%.
Postoperative vital signs, Aldrete, blood loss and urine output were recorded in 14 (1.74), 795 (98.64), 747 (92.68) and 607 (75.31) charts, respectively. The average rate of completion for postoperative information was 67.09%.
The Apgar score was not recorded in any of the charts reviewed. Time of delivery and the condition at birth were respectively recorded in 799 (99.13%) and 690 (85.61%) charts. Average rate of completion for birth information was 61.58%.
This column was only recorded in 295 (36.59%) charts.
| Discussion|| |
Despite the fact that all patients had anaesthesia charts, the chart completion rate in this study of 63.88% was low. It is mandatory for anaesthetists to keep records during all the cases of general and regional anaesthesia in our teaching hospital. However, this has not resulted in an efficient records system. All cadres of anaesthetist kept these records. This low rate was similar to a pre-intervention chart completeness rate of 56.1% in a previous study in the sub-region. Emergency procedures had a statistically lower chart completion rate than elective procedures. This study has found that chart completion rates were statistically poorer in emergency surgeries agreeing with a similar finding by Elhalawani et al. The reason for this may be that emergency surgeries are performed by fewer staff in a more stressful and hurried state that may predispose to poorer records keeping.
While it may be expected that demographic information would be the most frequently documented data group, it was surprising to find that a few charts (0.5%) did not even have the name of the patient recorded. The patient’s weight was not recorded in any of the charts. This suggests that the anaesthetists placed minimal emphasis on the calculation of accurate drug doses preferring rather to prescribe standard adult doses. The impact of this on the quality of anaesthesia delivery needs to be further studied.
Preoperative information was poorly recorded at 42.0% completion rate. Anaesthetists paid little attention to preoperative investigations and premedication. Simmonds and Petterson also found that preoperative record keeping was poor. Anaesthetist needs to pay more attention to preoperative information because inadequate review of these has been found to contribute to death, morbidity, Intensive Care Unit (ICU) admission and case cancellation. Co-exiting medical conditions can be discovered, treated or controlled, if more attention is placed on preoperative information. Attention to preoperative information is particularly important when the anaesthetist who conducted the preoperative assessment is different from the one conducting the anaesthesia.
Monitoring is one of the core tasks of the anaesthetist. The record of intraoperative data showed that vital signs were only documented with a 58.93% completion rate. In a study, it was found that most of the accidents solely attributable to anaesthesia among one million patients of American Society of Anesthesiologists (ASA) Physical Status I and II could have been prevented by appropriate response to warnings from safety monitoring. The record of intra-operative vital signs will allow the detection of trends that could predict adverse events and permit their prevention.
The critical incident section of the anaesthesia record had a chart completion rate of 36.59% in our study. When the incidences of manually recorded perioperative adverse events were compared with automatically detected events in another study, it was shown that anaesthetists manually recorded one-third of the adverse events recorded by the automated system. Manual recording, therefore, underestimate the true incidence of critical incidents.
In a study by Raff and James, it was found that the standard of record keeping fell far short of the minimum acceptable standard because less than one-third of all records were complete and legible, no records were kept in one quarter of all anaesthetics and the remaining 45% were incomplete or illegible. Despite the well documented superiority of automated records over manual records in improving chart completion rates, anaesthesia records continue to be manually recorded in many health facilities in Nigeria. Several barriers to the adoption of automated electronic medical records such as financial, technical, social and organizational challenges have been identified. These challenges may place this method out of the reach of many health institutions in the West African sub-region. Another viable method of improving chart completion in anaesthesia may involve teaching anaesthesia staff the importance of keeping records which has been found to improve chart completion rates.
| Conclusion|| |
Manual recording of anaesthesia information is unreliable and results in incomplete anaesthesia records. A comprehensive approach that would include structured teaching on the importance of chart completion and the use of automated information systems in recording may correct this anomaly.
We acknowledge the management of the University of Ilorin Teaching Hospital for granting approval for the study and the staff of the surgical wards for their cooperation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Roach WH, Hoban RG, Broccolo BM, Roth AB, Blanchard TP. Medical records requirements. In: Roach WH, editor. Medical Records and the Law. 4th ed. Sudbury, Massachusetts: Jones and Bartlett Learning Publishers; 2006. p. 31-50.
Reich DL, Wood RK Jr, Mattar R, Krol M, Adams DC, Hossain S et al.
Arterial blood pressure and heart rate discrepancies between handwritten and computerized anesthesia records. Anesth Analg 2000;91:612-6.
Olateju SO, Adenekan AT, Owojuyigbe AW. The effect of teaching on the completeness of the anesthesia record charts for obstetric subarachnoid blocks in a low resource area hospital. J Obstet Anaesth Crit Care 2015;5:16-21. [Full text]
Raff M, James MF. An audit of anaesthetic record keeping. South Afr J Anaesth Analg 2003;9:7-9.
van Schalkwyk JM, Lowes D, Frampton C, Merry AF. Does manual anaesthetic record capture remove clinically important data? Br J Anaesth 2011;107:546-52.
DesRoches CM, Campbell EG, Rao SR, Donelan K, Ferris TG, Jha A et al.
Electronic health records in ambulatory care − A national survey of physicians. N Engl J Med 2008;359:50-60.
Boonstra A, Broekhuis M. Barriers to the acceptance of electronic medical records by physicians from systematic review to taxonomy and interventions. BMC Health Serv Res 2010;10:231.
Elhalawani I, Jenkins S, Newman N. Perioperative anesthetic documentation: Adherence to current Australian guidelines. J Anaesthesiol Clin Pharmacol 2013;29:211-5.
] [Full text]
Simmonds M, Petterson J. Anaesthetists’ records of pre-operative assessment. Clin Perform Qual Health Care 2013;8:22-7.
Eichhorn JH. Prevention of intraoperative anesthesia accidents and related severe injury through safety monitoring. Anesthesiology 1989;70:572-7.
Benson M, Junger A, Fuchs C, Quinzio L, Böttger S, Jost A et al.
Using an anesthesia information management system to prove a deficit in voluntary reporting of adverse events in a quality assurance program. J Clin Monit Comput 2000;16:211-7.