Abstract
Background
Accurate and detailed documentation of anaesthesia records is crucial for maintaining patient safety and delivering high-quality perioperative care. Well organized documentation either electronic or manual is mandatory for providing good care or performing research. This research aimed to evaluate the adequacy of electronic anaesthesia record sheets for surgical patients at Hakim Gizaw Hospital.
Methods
A retrospective cross-sectional method was used to examine the electronic anaesthesia records of 179 surgical patients from January 2024 to June 2024 G.C. The completeness of these records was evaluated according to specific criteria encompassing preoperative, intraoperative, and postoperative documentation.
Results
The assessment identified shortcomings in the comprehensiveness of electronic anaesthesia record forms, particularly in documenting preoperative evaluations, intraoperative occurrences, and postoperative incidents. Notable areas of insufficiency included recording medication administration, monitoring vital signs, and documenting anaesthesia-related complications
Conclusion
The overall incidence of perioperative electronic anaesthesia documentation at Hakim Gizaw Hospital is 71.47% whereas the rate of not documented and not applicable documentation is approximately 21.2% and 7.33% respectively. Improving the completeness of electronic anaesthesia records is vital for enhancing patient safety and perioperative care quality.