title: Anaesthetists' records of pre-operative assessment.
abstract: The pre-operative anaesthetic records of 195 patients were analysed for the presence of 12 agreed core items of pre-operative assessment. This study showed that anaesthetists recorded 26.8 per cent of this information. In up to one-third of patients the following were recorded: smoking history, family history, gastro-oesophageal reflux, airway assessment, dental assessment, chest examination, heart-sounds and blood pressure. Previous anaesthesia, drug history and allergies were recorded in one to two-thirds of patients. Past medical history was recorded in over two-thirds of patients. With a view to improving the level of record-keeping, a formatted, pre-printed pre-operative assessment record was introduced into practice and two months later the audit was repeated. A small but non-significant improvement in record keeping was observed. An argument is made for the introduction of an interdisciplinary, unified anaesthetic pre-operative record.
authors.affiliation: Department of Anaesthetics, Royal Gwent Hospital, Newport, Wales, UK.
authors.forename: M
authors.initials: M
authors.lastname: Simmonds
authors.forename: J
authors.initials: J
authors.lastname: Petterson
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000776:Anesthesiology / Q000592:standards*; D004282:Documentation / Q000592:standards; D004739:England; D006801:Humans; D008485:Medical Audit / Q000706:statistics & numerical data*; D008499:Medical Records / Q000592:standards*; D008875:Middle Aged; D011300:Preoperative Care; D018570:Risk Assessment