An Audit of Anaesthesia Record-keeping at the Lagos University Teaching Hospital

Background: The anaesthetic record documents how individual patients respond to surgery and anaesthesia. It is an essential part of patients’ medical records. We conducted an audit cycle of anaesthetic records to determine accuracy and completeness of records and any effects on record-keeping after feedback. Patients and Methods: All anaesthetic record charts filled for elective and emergency surgeries over a one month period were prospectively and anonymously scrutinised for completeness of records. A re-audit of 100 charts was performed after feedback of results to the department to determine any improvement in documentation. Results: One hundred anaesthetic charts were studied in each audit. 6% of anaesthetic charts were completely filled in both audits. The only variables to be recorded 100% in both audits were the patient’s name and type of airway device inserted in patients that had general anaesthesia. There was an improvement in records of all demographic data but only weight recorded a significant improvement from 31% to 47% (p=0.02). Preoperative clinical data that recorded significant improvement in the re-audit were Pre-operative history (51% to 91%