title: Perioperative anesthetic documentation: Adherence to current Australian guidelines.
abstract: OBJECTIVE
  The lack of adequate perioperative documentation has legal implications and can potentially affect the quality and safety of patient care. Despite the presence of guidelines, the adequacy of perioperative documentation in Australasia has not been adequately assessed. The aim of this study is to assess the adequacy of anesthetic documentation on the pre and intraoperative encounters and to test the hypotheses that documentation is incomplete in the settings of emergency vs. elective procedures, regional vs. general anesthesia, and manual vs. electronic documentation.
  
  
  METHODS
  The study was an observational retrospective study in the setting of a 250-bed teaching hospital in metropolitan Adelaide, Australia. The perioperative records of 850 patients were analyzed. A scoring system was designed, based on a policy statement from the Australian and New Zealand College of Anesthetists and a survey of the hospital anesthetists. Scored and categorical data was analyzed using Chi-square test. Numerical data was analyzed using student t-test. The null hypothesis was accepted or rejected at 0.05 significance.
  
  
  RESULTS
  There were significant deficiencies in the adequacy of preanesthetic and intraoperative records. This has been shown to be true in all cases. Documentation was found to be poorer in the emergency setting when compared to elective cases (median scores 15 vs. 21 P = 0.03) as well as documentation of airway assessment for cases done solely under regional anesthesia (42 vs. 85%, P = 0.05). There were no significant differences in the adequacy of electronic vs. manual records (P = 0.92).
  
  
  CONCLUSIONS
  There are significant deficiencies in the adequacy of perioperative records. This has been shown to be true in all cases, but is especially so in emergency cases and for patients having only regional anesthesia.
authors.affiliation: Department of Anaesthesia, Queen Elizabeth Hospital/Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, South Australia, Australia.
authors.forename: Islam
authors.initials: I
authors.lastname: Elhalawani
authors.forename: Simon
authors.initials: S
authors.lastname: Jenkins
authors.forename: Nicole
authors.initials: N
authors.lastname: Newman
keywords: Anesthesia; documentation; electronic; emergency; regional