Intraoperative Anaesthesia Chart Completion-A Retrospective Observational Study

INTRODUCTION: Intraoperative anesthesia chart is an important document for perioperative patient care, research, academic purpose as well as for medico-legal purpose. The objective of our study was to find out the completeness of intraoperative anesthesia chart during routine surgeries performed under general or regional anesthesia. METHOD: It was a retrospective, observational study. All the anesthesia charts of the routine surgeries conducted in general or regional anesthesia over a period of one month were collected from the hospital record section and analyzed for their legibility as well as completeness in terms of patient identification details, surgery planned and performed preoperative and intraoperative vitals, anestheƟ c drugs and their dosage used, any adverse events, etc. RESULT: A total of 156 routine surgeries were performed in the period of one month under general or regional anesthesia but 49 anesthesia charts were found missing from the patient chart. So only 107 anesthesia charts were analyzed. Sixteen of these charts were not legible. Completeness of the charts in terms of patient identification details was 61%, for preoperative vitals- 27%, mention of anesthesia drug used and their dosage- 89% and 84% respectively, intraoperative vital charting- 72%. Only 13 charts mentioned specifically about any adverse event during the intraoperaƟ ve period. CONCLUSION: The completeness of intraoperative anesthesia charts was found to be very poor in our setup, with none of the item studied reaching 100% completeness. KEY WORDS: Anaesthesia chart, Anaesthesiology Standards, Documentation, Intraoperative, Medical Record