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 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 <50% was considered as areas of the critical need for improvement. SPSS version 20 was used for data analysis. Results: A total of 164 intraoperative anesthesia record tools were reviewed, and none of the indicators had a completion rate of 100%. The intraoperative anesthesia record tools completion rate was >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 (<50%) completion rate. Conclusion and Recommendation: Most of the indicators for manual intraoperative anesthesia recording were found incomplete and below the standards. Different strategies like regular feedback and monitoring to improve the practice have to be instituted. Introducing an electronic recording system may also help to overcome the problem.