Background and Aims SWBH Trust introduced anaesthetic electronic patient record (EPR) from September 2021.
We conducted Audit of anaesthetic records before and after introduction of EPR with AAGBI record keeping guidelines as the standard.
The aim was to compare informations recorded using the scanned-in anaesthetic paper chart on the trust electronic system and new EPR.
Methods 60 patients records, who had undergone anaesthesia at the Trust, were randomly selected for each audit in May and December 2021.
We analysed anaesthetic charts availability, patients details, name of clinicians involved, drugs administered, details of airway management, how well observations were recorded, overall legibility of records and completion of recovery handover.
Results We found significant overall improvement in record keeping after the introduction of the EPR.
100% EPR charts available Vs 80% scanned-in paper charts, vital observations 100% vs 90%, airway management 100% vs 76%, anaesthetist name 100% vs 95%, overall legibility 100% vs 90%, documented recovery handover 100% vs 80%.
Conclusions Our EPR satisfies the current AAGBI guidelines recommending “automated electronic anaesthetic record systems, with an accurate summary of information provided by all monitoring devices”.
EPR pre-populates anaesthetic procedures, it’s time efficient as it automatically uploads key information of patient, surgery details and clinicians involved. Drug names and doses administered are recorded easily. This minimises documentations errors producing highly legible, good quality document. Automatic digital interface between observation monitor and computer allows instantaneous recording of observation
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