Evaluation de la tenue du dossier d'anesthésie

Objective: To assess the quality of the anaesthetic record for surgical and non surgical procedures and for elective and emergency surgery. Study design: Retrospective study in a university hospital. Material and methods: Anaesthetic records collected over one month were analysed. The record included a referential with 38 items: nine for the identification of the patient and those who completed the record, 16 for the preoperative period and 13 for the operative period. Each item was qualified either as present (or correct), or absent, or unreadable or not applicable. Results: Overall, 2,422 anaesthesia records were analysed, including 88,732 items. The mean level of correct items was 72%, and 1% of them were unreadable. Items for identification were significantly more correctly recorded (86%) than those concerning the preoperative (63%) and the operative (73%) periods (P < 0.01). Anaesthetic data for surgical procedures were significantly more correctly recorded (73%) than those for non surgical procedures (63%) and surgery under local anaesthesia (52%; P < 0.01). Emergency surgical procedures were significantly less correctly recorded than elective ones (70 vs. 72%; P < 0.01). Conclusions: These results suggest that the quality of the anaesthetic records should be improved, mainly for the preoperative period and for non surgical procedures.