An Audit of Anaesthetic Record Charts in the Orthopaedic Theatre of a Nigerian Teaching Hospital

ABSTRACT

Objective: The anaesthetic record is an essential part of a patient's record; providing useful information for the management of the patient. It is of medico-legal importance and can be used for quality assurance and researchpurposes. An analysis of anaesthetic record charts from a satellite operating theatre of the University of Port-Harcourt Teaching Hospital (UPTH) was undertaken to determine their legibility; correctness and completeness. Method: A retrospective analysis of the anaesthetic record charts from March 2003 to February 2004 of the orthopaedic theatre of the UPTH was undertaken. Results: A total of 232 anaesthetic record charts were analyzed. All entries were manually-written. Of these; 141 (60.9) were filled by anaesthetic registrars; the rest were filled by senior registrars 85 (36.5) and consultants 6 (2.6). One hundred and twenty-one charts (52.2) were legible; completely and correctly filled; but 47.8were incompletely filled; and 47.7had at least an illegible parameter. Conclusion: It is concluded from this analysis that the standard of anaesthetic record-keeping needs to be improved and consideration given to the use of computer-generated records which will eliminate the problems of illegible records