Evidence Based Practice and Quality Assurance
Background and Goal of Study: This project was undertaken to ascertain the quality of documentation associated with anaesthesia in Scotland. In 1996, recommendations as to the content of the anaesthetic record chart were published by the Royal College of Anaesthetists (RCOA)1. A 1997 study2 in North West England concluded that no anaesthetic chart compiled fully with these guidelines and suggested a review of the design of their charts.
Materials and Methods: We have performed a similar exercise and examined charts from 27 of the 29 NHS departments administering anaesthesia in Scotland. We also audited 202 ‘completed’ charts in two district general hospitals against the RCOA guidelines. This was in order to assess documented information, irrespective of printed data fields.
Results and Discussions: No Scottish anaesthetic chart was fully compliant with current guidelines, with the mean number of recommended fields present being 50% (23-80%). In the two hospitals studied the anaesthetist present was only recorded on 68% and 85% of occasions respectively and the timing of drugs and fluid administration in 69% and 97% of cases. The fields for ‘name of patient’ and ‘operation performed’ were not present on 100% of forms! These omissions of information could cause problems for future anaesthetics or make legal cases less defensible and accountable.
Conclusions: There has been little improvement in standards of documentation and certain fields are consistently omitted. The anaesthetic chart is not a legal requirement but it could be construed that a lack of documentation reflects inattention of the anaesthetist for the patient3. We have designed an anaesthetic chart that meets the RCOA criteria and could potentially be implemented throughout Scotland. It is available online at http://www.show.scot.nhs.uk/wlt/anaesthesia.asp
1 Royal College of Anaesthetists. Newsletter 1996; 27: 8-9.
2 Smith A. New College guidelines for anaesthetic records - How do current forms measure up? Royal College of Anaesthetists. Newsletter 1997; 36.
3 National Health Service Executive. Patients' Charter. London: Statienary Office 1996.