An audit of anaesthetic charts at Chris Hani Baragwanath Academic Hospital

Abstract

Background: The anaesthetic chart is an important component of a patient’s health record in the perioperative period. Studies have shown that anaesthetic charts are often incomplete. The adequacy of chart completion in the anaesthetic department at Chris Hani Baragwanath Academic Hospital (CHBAH) has never been quantified. An audit was done, and the charts were assessed for adequacy of completion. Methods: A retrospective audit of anaesthetic charts was done for the year 2019. Using a peer reviewed checklist adapted from the Australian and New Zealand College of Anaesthetists (ANZCA) and the South African Society of Anaesthesiologists (SASA) guidelines, a sample of 333 charts was audited to assess adequacy of completion. To eliminate sampling bias, a stratified sampling method was used. Results: Completeness was defined as a chart scoring 100%. None of the charts scored 100%. The overall median score of the charts was 77%. Charts were subdivided into three groups. Charts scoring between 75-99% (n=212), 50-74% (n=121) and charts less than 50% complete (n=0). Patient category (adult versus paediatrics), time of shift (day versus night) and type of anaesthetic were audited and compared as factors that could affect chart completeness. The only factor that had a statistically significant difference in chart completeness was the patient category, where adult chart completion scored higher compared to paediatric charts with a p-value <0.0074. Conclusion: In conclusion the charts audited scored higher than previous audits done both locally and internationally. Some important aspects of the charts were poorly documented. Ongoing audits and training on chart completion can potentially improve the adequacy of completion and should be part of the academic program. Better documentation has the potential to improve perioperative patient care and mitigate medicolegal risks.