Audit of Anaesthetic Chart Documentation in Major Orthopaedic Surgery

Abstract

Objective: To investigate the completeness of documentation of anaesthetic charts in elective orthopaedic anaesthesia.

Design: Data collection from medical records.

Setting: Orthopaedic department, teaching hospital.

Participants: Anonymous anaesthetic consultants participating in orthopaedic surgery.

Intervention: E-mail and verbal message regarding 2nd data collection to anaesthetic colleagues.

Main outcome measures: Documentation of data of variables on anaesthetic chart.

Results: Good documentation of most variables. An average improvement of 5.7% in data documentation, range of −2.7% to 24.7%. Poor documentation of blood loss and urinary output.

Conclusions: The importance of the anaesthetic chart cannot be underestimated. A close working relationship with ones colleagues in anaesthesia promotes a fuller use of the chart and contributes to its continued development as a source of information.