Type of publication:
*Cunningham D.; *Travis M.; *Leach S.
Anaesthesia; Jul 2019; vol. 74 ; p. 27
Incomplete or poor quality peri-operative documentation has both clinical and legal implications. As such, anaesthetic professional bodies issue guidance relating to documentation. It is unclear to what extent this guidance is followed by anaesthetists in our hospital. We aimed to improve the quality of documentation through excellence reporting and to test this methodology as a means of implementing change.
Methods: The completeness of anaesthetic charts (n = 50) are analysed annually over a 1- week period, using a proforma. The proforma highlights details that should be included as part of the peri-operative documentation. Several months prior to collection of the 2018 data, we initiated an excellence reporting project. This involved analysing a sample of charts on alternate weeks over a 12-week period. The five anaesthetists with the most complete charts were issued with a certificate. The anaesthetist with the highest scoring chart won a prize. Results were publicised on posters and presented at monthly governance meetings. If multiple charts scored full marks, judgement was used to determine the winner. Following this intervention period, results from the 2018 annual audit were compared with data from the previous year.
Results: The annual audit requires that the anaesthetic charts be scored on 27 key points outlined in the proforma. In 2018, 13 categories scored greater than 95% completeness with the remaining 14 categories scoring less than 95% completeness. In 2017, 10 categories scored greater than 95% completeness with 17 scoring less than 95%. The 2018 data scored greater than or equal to the 2017 data in 16 categories. In the other 11 categories, the 2017 data scored higher. Legibility is not considered in the annual audit but subjectively appeared to improve over the period of excellence reporting.
Discussion: Through the use of excellence reporting, we have seen some improvement in the completeness and legibility of peri-operative documentation in our hospital. This outcome suggests that excellence reporting is a useful tool for managing positive change. However, both data from 2017 and 2018 did not reveal 100% completeness in all categories, and with the potential legal and clinical ramifications, it is important that we continue to improve anaesthetic documentation.
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