Perioperative documentation: are we doing enough?

ABSTRACT

We performed a retrospective analysis to assess the content and accuracy of operative and anaesthetic records for Caesarean section in a large unit. The obstetric record was considered adequate if it included patient identification, participating doctors, operative date, title, details and findings and a signature. The anaesthetic record was evaluated by The Australian and New Zealand College of Anaesthetists guidelines. We analysed 104 operative and 101 anaesthetic records. There was inadequate identification in 17 (16.3%) of the operative records. Documentation of a previous scar or the presence or absence of intraabdominal adhesions was incomplete in 22 of the 35 patients (63%) with a previous laparotomy. Sixty per cent of records had incomplete skin closure information. Common anaesthetic record deficiencies were patient position, patient airway, investigation results and postoperative plan. Our findings identified deficiencies that could lead to inadequate medical care and indicate the need for improved standards of perioperative records.