Quality Assessment of Manual Anaesthesia Chart Documentation in a Nigerian Teaching Hospital

Abstract

Background: Clinical record keeping is an important component of good professional practice. Accurate documentation serves as a critical communication tool among healthcare providers. Aim: To identify gaps in documentation, assess compliance with established standards, and provide a basis for implementing targeted interventions. Method: A retrospective review conducted in the main operating theatre of the University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria, with six theatre suites (emergency, gynaecology, urology, general/cardiothoracic, orthopaedic, and neurosurgery). Data were collected using a structured review of anaesthetic records. Statistical analysis by SPSS version 27.0. Frequencies and percentages were calculated, and associations between chart availability and documentation quality were assessed using Chi-square tests, with statistical significance set at P < 0.05: Result: A total review of anaesthetic charts showed variable completeness across perioperative documentation. Demographic data were moderately completed, with key identifiers such as name, age, and gender documented in nearly all cases, while ward (22.7%) and bed number (10.1%) were poorly recorded. Intraoperative documentation demonstrated high completeness overall (median ≈99%), with most parameters exceeding 95%. However, temp (15.1%) and RR (38.2%) were poorly documented. Postoperative monitoring showed generally low completeness, particularly for RR (28.1%), temp (34.8%), signature (29.7%), and date (17.0%), although blood pressure (92.6%) and PR (96.4%) were well recorded. Overall, documentation quality was high intraoperatively but suboptimal in demographic and postoperative sections. Additionally, most charts were completed by registrars (82%), followed by senior registrars (14%) and consultants (3.6%). Conclusion: Anaesthetic documentation in this study was satisfactory in the intraoperative phase but suboptimal in demographic and postoperative sections, with critical gaps in monitoring parameters and patient identifiers. The predominance of documentation by junior trainees highlights the need for improved supervision, structured documentation systems, and targeted training.