Completion and accuracy in charting of anesthetic records in Songklanagarind Hospital.

ABSTRACT

OBJECTIVE: To audit the completeness and accuracy in charting of anesthetic recorded by hand. MATERIAL AND METHOD: A retrospective descriptive study from 890 checklist forms. The classification of complete record as good level and incomplete record including level of fair, poor or no data. The frequency, percentage and the difference of completeness and accuracy in charting of anesthetic records were analyzed by Chi-squared test. RESULTS: The item of vital signs during anesthesia was one of 44 items that were 100% complete and accurate. The overall average of completeness and accuracy in terms of good, fair, poor quality, and no data was 94.5, 3.1, 0.4, and 2%, respectively. Twenty-two of 44 items had statistically significant difference between complete and incomplete records. CONCLUSION: The charting of anesthetic record remained incomplete and inaccurate in 43 from 44 items, except the item of vital signs. The average of good anesthetic record was 94.5%. The incomplete anesthetic records were caused by illegibility, incorrect data filling, no data, or incomplete detail of each item such as incorrect ASA classification, or problem list etc. Handwritten records should be carefully filled-in to increase completion so that the data could be used as legal evidence.