CLINICAL AUDIT

Department of Anaesthesiology
GKGH and GAIMS, BHUJ
 TITLE

A clinical audit on the practice of

documentation at
preanaesthetic evaluation in a
tertiary care hospital
 Introduction
• Preanaesthetic evaluation improves patient safety
and optimization, resource utilization and prevent
unnecessary delay or cancellation of a case.1,2,3

• Inadequate preoperative evaluation and poor patient

preparation are two important factors that lend up
with increased anaesthetic complications and
mortality.4,5,6
• Inadequate documentation and poor record keeping
are challenges for quality care and better patient
outcome.7,8

• Different institutions are using different formats of

preanaesthetic evaluation. Using standardized
preanaesthetic evaluation tool can help to elaborate
and keep quality information.7,9

• The general objective of the current audit is to assess

the practice of documentation at preanaesthetic
evaluation and completeness of form.
 Materials and methods
• This audit was conducted at Dept. of
Anaesthesiology, GK General hospital and GAIMS,
Bhuj.

• The Department provides PAC service to General

Surgery, Orthopaedic, ENT, Ophthalmology, Obs. and
Gynaecology, Psychiatry department.

• To conduct the audit project, documents of all

consecutive patients came for elective operation
were reviewed.
• A checklist was developed by the investigators based
on the indicators in the modified Global Quality Index
(GQI).

• 18 quality practice indicators were selected from the

GQI and labeled as
– YES – for complete documentation
– Partial – incomplete documentation
– NO – if left blank

• For each item, completeness was predefined by

components of the item (TABLE 1).
 TABLE 1: Indicators drawn from modified GQI
Indicators Predefined components for completeness
Patient’s name Name of the patient including last name
Age Value with unit
Gender
Date of visit Date/month/year
Preoperative diagnosis
Surgical procedure
Past medical history Previous or co-existing illness with duration and treatment
Medication Type, dose and route
Anaesthetic history Surgical procedure, anaesthetic type, time and any complication
Allergies Triggers and extent of reaction
Preoperative vital signs Heart rate, Blood pressure, Respiratory rate
Weight Value with unit
Airway At least mallampati view, neck movement, TM distance,
Dentition Site and status
CVS examination Auscultation
RS examination Inspection and auscultation
ASA class Class
Plan of anaesthesia At least first plan and what was discussed with the patient
• Expected completion rate was 100% for all indicators.
– Indicators with >90% completion rate were marked as
acceptable
– Completion rate <50% was considered as areas of critically
need improvement

• The data were checked and entered in Microsoft

excel and analyzed with appropriate statistical tests.
Results were expressed in frequency and percentage.
 Results
• A total 300 preanaesthetic evaluation forms used to
assess patients undergoing elective surgical
operation were reviewed during the study.
 Table 2: Completion rate of indicators
Indicators Yes Partial No
No. (%) No. (%) No. (%)
Patient’s name 173(58) 124(41) 3(1)
Age 299(99.67) 0(0) 1(0.33)
Gender 296(98.67) 0(0) 4(1.33)
Date of visit 299(99.67) 1(0.33) 0(0)
Preoperative diagnosis 270(90) 0(0) 30(10)
Surgical procedure 300(100) 0(0) 0(0)
Past medical history 254(84.67) 2(0.67) 44(14.67)
Medication 204(68) 38(12.67) 58(19.34)
Anaesthetic history 290(96.67) 1(0.33) 0(0)
Allergies 63(21) 0(0) 237(79)
Preoperative vital signs 300(100) 0(0) 0(0)
Weight 299(99.67) 0(0) 1(0.33)
Airway 300(100) 0(0) 0(0)
Dentition 300(100) 0(0) 0(0)
CVS examination 300(100) 0(0) 0(0)
RS examination 300(100) 0(0) 0(0)
ASA class 294(98) 0(0) 6(2)
Plan of anaesthesia 299(99.67) 0(0) 1(0.33)
Discussion
• Patient identity is a basic component of medical
record. A name is one of the identifiers used in
clinical practice.6 Though found satisfactorily
recorded, practice needs to improve as 41% were
recorded partially.

• Medication history helps to recognize possible

interactions and need for perioperative
administration.10 As found in literature, less proper
preoperative instructions found to be contributing
factor for perioperative medication errors.11, 12
Medical and medication history were recorded in
85% and 81% respectively.
• The incidence of allergic reactions during anaesthesia
is estimated 1: 10,000- 20,000. The commonest
causing agents are neuromuscular blocking agents,
latex and antibiotics.13, 14 So careful evaluation and
documentation can help to identify and avoid
triggers.

• Explanation for the above mentioned low records in

past medical, medication history and allergic history
is that they were recorded in form when it was
present as positive history. Not mentioned as
negative one.
 Conclusion
• Indicators with high completion rate (>90%) were
patients name, age, gender, date of visit,
preoperative diagnosis and surgical procedure, past
anaesthetic history, preoperative vitals, weight,
Airway, dentition CVS and RS examination, ASA
physical status and Plan of anaesthesia.
• Scope of improved documentation –
– Complete name
– Detailed past medical and medication history
– Negative history for allergy.
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