Audit of anaesthetic chart documentation in private hospitals in Port Harcourt, Rivers State, Nigeria

Background: The Anaesthetic chart is a vital tool that depicts correct documentation of perioperative anaesthetic management of patients; it ensures standard of care, continuity of care and medico-legal protection when filled properly. The aim of this study was to evaluate the availability and quality of anaesthetic chart documentation and the factors that affect the routine use in private hospitals in Port Harcourt, Rivers State, Nigeria.

Methods: This was a one-year retrospective review of anaesthetic record-keeping in five high- volume private hospitals in Port Harcourt. Information on the use, appropriateness and legibility of the anaesthetic charts were obtained. Data analysis was done with SPSS version 20.0. Chi-square tests were used to determine the relationship between chart availability and documentation quality, with statistical significance defined as P < 0.05.

Results: All 5 hospitals had anaesthetic charts. Records of 442 surgeries were assessed, 300 (67.9%) surgeries had anaesthetic charts while 142 cases (32.1%) had no charts filled. Of the 300 charts, 105 (35.0%) were correctly filled, 118 (39.3%) were incompletely filled, and 77 (25.7%) were not legible. Chi-square analysis showed that there was no statistically significant association between availability of charts and documentation quality (χ² = 5.07, P = 0.167).

Conclusion: Anaesthetic charts were filled in majority of surgeries carried out; however, the quality of documentation was unsatisfactory and needs to be improved upon