Audit of Anaesthesia Chart Completion at the University College Hospital, Ibadan

Abstract

Abstract Background: The anaesthesia chart is a vital component of the medical record of patients undergoing anaesthesia. It is often the sole record of peri-operative events available to the anaesthetist and, therefore, should be comprehensive, accurate, and clear. Unfortunately, it has been repeatedly noted to be poorly completed. An audit of the anaesthesia chart is, therefore, key in improving peri-operative care and minimising medico-legal risks. Methods: The study was a prospective audit of anaesthesia charts at the University College Hospital, Ibadan. To assess chart completeness, a checklist was designed based on variables from the currently used anaesthesia chart. All anaesthesia charts of patients who underwent general or regional anaesthesia at all operating theatres in February 2024 were included. Results: One hundred and eighty-eight charts were analysed in this audit. The mean percentage chart completion was 72.0 ± 7.3%. The minimum score was 33.3%, while the maximum was 88.3%. One chart (0.6%) scored < 50%, 125 (69.4%) scored 50%–74.9%, while only 54 charts (30%) scored ≥ 75%. The demographic section was better completed than the pre-operative and intra-operative sections (91.2%, 55.9% and 68.7% respectively). Charts of elective procedures were better completed than those of emergency procedures. The patient’s age group, anaesthetic technique or grade of anaesthetist completing the chart did not affect chart completion. Conclusion: The anaesthesia chart is an often-overlooked but essential part of anaesthesia practice. This audit revealed that charts were not adequately filled. This has far-reaching medico-legal implications.