Assessment of perioperative anesthesia record sheet completeness: A multi-center observational study

BACKGROUND: Anesthesia record is an essential part of perioperative patient management and, it is one of the global patient safety challenges. The aim of this study is to assess the completeness of perioperative anesthesia record sheets in Amhara regional state hospitals of Ethiopia. METHODS: A retrospective review of anesthetic records was employed for patients who underwent surgery in Amhara Regional State Hospitals of Ethiopia from December 1, 2019, to February 29, 2020. All the intraoperative, preoperative, and postoperative data completeness of anesthesia record sheets was assessed using a structured checklist. RESULTS: A total of 420 perioperative anesthetic records were included in this study. The basic preoperative history was documented in less than 80% of anesthesia record sheets. A physical examination was done and the results of the basic investigations were recorded in less than 75% of anesthesia record sheets. The name and dose of anesthetic medications were documented in 91% of the anesthesia records sheets. The completeness of parameters related to postoperative plans and orders was less than 70%. CONCLUSION: The completeness of perioperative anesthesia record was poor in Amhara regional state hospitals of Ethiopia. Anesthesia professionals should document all the necessary perioperative parameters in the anesthesia record sheet.