Assessing the completeness of perioperative anesthetic record documentation in a tertiary hospital

Background and Objective: Many previous studies assessing the completeness of perioperative documentation of surgical patients were reported to be inadequate and unsatisfactory. The aim of this study was to compare the perioperative anesthetic record (PAR) at our tertiary care institution to a standard guideline and have an audit of its completeness. Methodology: It was a prospective, observational study, done in the general operating theater of Universiti Kebangsaan Malaysia Medical Centre (UKMMC). We compared our PAR to the American Society of Anesthesiologists (ASA) policy statement on documentation of anesthesia care. We audited the completeness of PAR documentation of 358 patients by using a self-generated checklist which was created in accordance to the PAR parameters. A total of 44 parameters were studied covering three phases; preoperative, peroperative and post-operative phases. Results: Although the UKMMC PAR varied from the ASA guidelines, various salient parameters were identical in both. None of the perioperative forms were completely filled throughout the three perioperative phases. Out of 44 parameters studied, only 2 parameters were completely filled, which were medications administered and fluid therapy. Conclusion: Parameters given in the UKMMC PAR varied with the ASA guidelines and the documentation was found to be only partially complete. Hence, necessary modification of the current PAR in our institution, and the stress on filling it completely is needed to improve the quality of perioperative anesthetic documentation. Keywords: Audit; Completeness; Perioperative; Anesthetic record; Documentation Citation: Bolhan HA, Yahya N, Izaham A, Mat WRW, Rahman RA, Musthafa QA. Anaesth. pain intensive care 2020;24(6):--- Received: 23 April 2020, Reviewed: 17 August 2020, Revised: 18 October 2020, Accepted: 27 October 2020

Modern Anesthesia and Its Medico-Legal Aspects

The practice of anesthesia has changed dramatically since the days of John Snow. The modern anaesthesiologist is now both a consultant and a primary care provider. The consultant role is appropriate because the primary goal of the anesthetist- to see the patient and comfortably through surgery- generally takes only a short time. However, because anaesthesiologist manage all "noncutting" aspects of the patient's care in the immediate perioperative period, they are also primary care providers. The "Captain of the ship"doctrin, which held the surgeon responsible for every aspects of the patient's perioperative care is no longer valid. The surgeon and anesthesiologist must function together effectively, but both are ultimately answerable to the patient rather than to each other. Patient can select their own anesthesiologist, as well as the surgeon. On the other hand an anesthesiologists have every rights to choice a surgeon, or refuse giving anesthesia to a certain patients. The practice of anesthesia is no longer limited to the operating room. The anesthesiologist are now routinely asked to monitor, sedate and provide general or regional anesthesia outside the operation room. Anesthesiologist have traditionally been pioneers in cardiopulmonary resuscitation and continue to be integral members of resuscitation team. Preoperative evaluation of patients, perioperative and postoperative monitoring and care is absolutely essential. Surgeon-anesthesiologist, anesthesiologist-patient rapport/ co-ordination should be maintained. Documentation is important for both quality assurance and medico legal purpose. Preoperative and intraoperative anesthetic record must be preserved as it serves many purposes. This record should as pertinent and accurate as possible. The written consent with a witness must be taken. The postoperative notes are also essential as many of the patients files complaint against the anesthesiologist, surgeon, and hospitals. Therefore, there are no alternatives rather to preserve all sorts of written documents for their own safety.KYAMC Journal Vol. 7, No.-2, Jan 2017, Page 806-809

Automated Documentation Error Detection and Notification Improves Anesthesia Billing Performance

Background Documentation of key times and events is required to obtain reimbursement for anesthesia services. The authors installed an information management system to improve record keeping and billing performance but found that a significant number of their records still could not be billed in a timely manner, and some records were never billed at all because they contained documentation errors. Methods Computer software was developed that automatically examines electronic anesthetic records and alerts clinicians to documentation errors by alphanumeric page and e-mail. The software's efficacy was determined retrospectively by comparing billing performance before and after its implementation. Staff satisfaction with the software was assessed by survey. Results After implementation of this software, the percentage of anesthetic records that could never be billed declined from 1.31% to 0.04%, and the median time to correct documentation errors decreased from 33 days to 3 days. The average time to release an anesthetic record to the billing service decreased from 3.0+/-0.1 days to 1.1+/-0.2 days. More than 90% of staff found the system to be helpful and easier to use than the previous manual process for error detection and notification. Conclusion This system allowed the authors to reduce the median time to correct documentation errors and the number of anesthetic records that were never billed by at least an order of magnitude. The authors estimate that these improvements increased their department's revenue by approximately $400,000 per year.