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Anaesthetists’ records of pre‐operative assessment

Mark Simmonds (Specialist Registrar in Anaesthesia, Department of Anaesthetics, Royal Gwent Hospital, Newport, Wales, UK)
Jane Petterson (Senior House Officer in Anaesthesia, Department of Anaesthetics, Royal Gwent Hospital, Newport, Wales, UK)

British Journal of Clinical Governance

ISSN: 1466-4100

Article publication date: 1 March 2000

Abstract

The pre‐operative anaesthetic records of 195 patients were analysed for the presence of 12 agreed core items of pre‐operative assessment. This study showed that anaesthetists recorded 26.8 per cent of this information. In up to one‐third of patients the following were recorded: smoking history, family history, gastro‐oesophageal reflux, airway assessment, dental assessment, chest examination, heart‐sounds and blood pressure. Previous anaesthesia, drug history and allergies were recorded in one to two‐thirds of patients. Past medical history was recorded in over two‐thirds of patients. With a view to improving the level of record‐keeping, a formatted, pre‐printed pre‐operative assessment record was introduced into practice and two months later the audit was repeated. A small but non‐significant improvement in record keeping was observed. An argument is made for the introduction of an interdisciplinary, unified anaesthetic pre‐operative record.

Keywords

Citation

Simmonds, M. and Petterson, J. (2000), "Anaesthetists’ records of pre‐operative assessment", British Journal of Clinical Governance, Vol. 5 No. 1, pp. 22-27. https://doi.org/10.1108/14664100010332964

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MCB UP Ltd

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