Background and Aims Obtaining consent for anaesthetic procedures and accurately documenting those discussions is vital for ensuring anaesthesia is delivered safely, legally and in a patient-centred manner. This single-centre audit aims to assess documentation of consent for anaesthesia and compliance with the Association of Anaesthetists of Great Britain & Ireland (AAGBI) 2017 guidelines1.
Methods Anaesthetic charts of patients undergoing elective procedures were audited over a 7-day period at a single site. Data on consent and documentation were collected based on AAGBI guidance. Ethical approval was not deemed necessary by the local audit team.
Results 104 patients were included, 102 undergoing general anaesthesia (GA) and 10 neuraxial blocks. 103 (99%) patients underwent pre-operative assessment and 96 (92%) received written information. There was documented explanation of and patient agreement to the procedure in 104 (100%) patients. Benefits were discussed in 1 (1%), alternative therapies in 2 (2%) and patient questions in 0 (0%) patients. Data on anaesthetic risks are included in tables 1 and 2.
Conclusions Documentation of anaesthetic consent was variable. This may be explained by the anaesthetic chart: sections of the consent process and risks that had allocated tick-boxes were consistently documented, those without tick-boxes were infrequently documented. Time-pressures on the consent process may also explain these findings. Effectively designed anaesthetic charts provide prompts to aid discussion and facilitate documentation. Following these findings, we aim to re-design the trust anaesthetic chart to better facilitate the consent process, improve the patient journey and protect clinicians. Re-auditing following this will aim to demonstrate quality improvement.
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