Assessment of Manual Intraoperative Anesthesia Record-Keeping Practice at Dilla University Referral Hospital, Dilla, Ethiopia

Introduction: Clinical record-keeping is a crucial part of professional practice and the delivery of quality healthcare. Poor intraoperative recording contributes to poor patient safety and unavailability of data in cases of medico-legal review or research purpose. Additionally, such records may pro...

Full description

Saved in:
Bibliographic Details
Published in:Open access surgery (Auckland) 2021-02, Vol.14, p.1-7
Main Authors: Zemedkun, Abebayehu, Mulugeta, Hailemariam, Getachew, Hailemariam, Destaw, Belete, Mola, Simeneh, Milkias, Mesay
Format: Article
Language:English
Subjects:
Analysis
Anesthesia
data quality
Documentation
Handbooks, vade-mecums, etc
Hospitals
Information management
intraoperative
Medical records
Medical referrals
Patients
practice
Professionals
Surgeons
Vital signs
Citations: Items that this one cites
Items that cite this one
Online Access:Get full text
Tags: Add Tag
No Tags, Be the first to tag this record!
Description
Summary:Introduction: Clinical record-keeping is a crucial part of professional practice and the delivery of quality healthcare. Poor intraoperative recording contributes to poor patient safety and unavailability of data in cases of medico-legal review or research purpose. Additionally, such records may provide an invaluable guide to subsequent practitioners involved with the patients' management. Method and Materials: A descriptive study was conducted at Dilla University Referral Hospital from October 1 to November 30, 2020. Fifty-one intraoperative record indicators were developed and those requiring a definition for completeness were predefined. The expected completion rate was 100% for all indicators. Indicators with >90% completion rate were marked as acceptable and completion rate of 90% for documentation of sex, procedure starting time, name of the procedure, dose/volume and route of a specific drug given, standards of monitoring used, intraoperative blood pressure, and pulse rate record with time. Patient identity, name of professionals, baseline oxygen saturation, unit of measures of baseline vital signs, patient's status on transfer, the total amount of each drug administered, intraoperative electrocardiographic rhythm, total amount of blood loss, total amount of urine output, and postoperative management plan were among indicators found below average (
ISSN:1178-7082
1178-7082
DOI:10.2147/OAS.S298387