Manual Anesthesia Record Keeping at a Tertiary Care Center: A Descriptive Cross-sectional Study. 2021

Mona Sharma, and Dikshya Karki, and Saurya Dhungel, and Ritika Gautam
Department of Anesthesiology, Kathmandu Medical College Teaching Hospital, Sinamangal, Kathmandu, Nepal.

BACKGROUND Intraoperative record form is one of the cardinal parts of anesthesia practices. Ideally, it should contain complete information about patients under anesthesia and intraoperative events. It serves as valuable information for subsequent patient management, research, or during medicolegal conditions. The objective of this study was to assess the practice and completeness of manual intraoperative anesthesia record keeping. METHODS A descriptive cross-sectional study was conducted from May 1 to July 31, 2021, in the postoperative ward of Kathmandu Medical College, which is a multispecialty tertiary care center. Approval from the ethical committee of Kathmandu Medical College Teaching Hospital was obtained (Reference: 2603202105) before conducting the study. Convenience sampling was used. The data were entered in Microsoft Excel and statistical analysis was done using Statistical Package for the Social Sciences version 20. Point estimate was done at 95% Confidence Interval and data present in numbers and percentages. We devised forty-two variables, which included demographics, personal identifiers, intraoperative events, anesthesia and airway management, intraoperative parameters, monitoring and medication. RESULTS The overall completion rate was 202 (52.59%) (47.6-57.57 at 95% Confidence Interval). Out of 42 variables, the completion rate of 14 variables was less than 50%. Among those were important parameters such as known allergies 94 (24.4%), Body mass index 50 (13%), intraoperative saturation of oxygen 104 (27%), intraoperative electrocardiogram recording 107 (27.8%), total fluid volume administered 45 (11.7%), patient status on transfer 84 (21.8%) had poor completion rate. CONCLUSIONS Our intraoperative record form shows poor completion rate, which was similar to other studies. many important variables were missing and had incomplete data.

UI MeSH Term Description Entries
D003430 Cross-Sectional Studies Studies in which the presence or absence of disease or other health-related variables are determined in each member of the study population or in a representative sample at one particular time. This contrasts with LONGITUDINAL STUDIES which are followed over a period of time. Disease Frequency Surveys,Prevalence Studies,Analysis, Cross-Sectional,Cross Sectional Analysis,Cross-Sectional Survey,Surveys, Disease Frequency,Analyses, Cross Sectional,Analyses, Cross-Sectional,Analysis, Cross Sectional,Cross Sectional Analyses,Cross Sectional Studies,Cross Sectional Survey,Cross-Sectional Analyses,Cross-Sectional Analysis,Cross-Sectional Study,Cross-Sectional Surveys,Disease Frequency Survey,Prevalence Study,Studies, Cross-Sectional,Studies, Prevalence,Study, Cross-Sectional,Study, Prevalence,Survey, Cross-Sectional,Survey, Disease Frequency,Surveys, Cross-Sectional
D006784 Hospitals, Teaching Hospitals engaged in educational and research programs, as well as providing medical care to the patients. Hospital, Teaching,Teaching Hospital,Teaching Hospitals
D006801 Humans Members of the species Homo sapiens. Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D000758 Anesthesia A state characterized by loss of feeling or sensation. This depression of nerve function is usually the result of pharmacologic action and is induced to allow performance of surgery or other painful procedures.
D062606 Tertiary Care Centers A medical facility which provides a high degree of subspecialty expertise for patients from centers where they received SECONDARY CARE. Tertiary Hospital,Tertiary Referral Center,Tertiary Referral Hospital,Care Center, Tertiary,Care Centers, Tertiary,Center, Tertiary Care,Center, Tertiary Referral,Centers, Tertiary Care,Centers, Tertiary Referral,Hospital, Tertiary,Hospital, Tertiary Referral,Hospitals, Tertiary,Hospitals, Tertiary Referral,Referral Center, Tertiary,Referral Centers, Tertiary,Referral Hospital, Tertiary,Referral Hospitals, Tertiary,Tertiary Care Center,Tertiary Hospitals,Tertiary Referral Centers,Tertiary Referral Hospitals

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