Improving Preoperative Care in Pakistan: An Evaluation of Pre-anesthetic Record Completeness and Documentation...

Introduction Accurate pre-anesthetic assessments are crucial for safe and effective anesthesia management. However, the completeness and quality of these assessments are often suboptimal, potentially impacting patient safety and surgical outcomes. This study evaluates the quality of preoperative assessments documented by anesthetists at a large private tertiary care hospital in Islamabad, Pakistan, focusing on adherence to standardized protocols and identifying specific deficiencies in documentation. Methods A retrospective descriptive study was conducted, reviewing 122 patient records from the General Surgery Department between October and December 2024. Pre-anesthetic record (PAR) forms were evaluated using a custom data collection tool based on the Global Quality Index (GQI). The tool assessed 16 key criteria for completeness, with each criterion categorized as "Yes-Complete" (fully documented with sufficient detail), "Yes-Incomplete" (partially documented but lacking essential details for comprehensive preoperative evaluation), or "No" (entirely missing). Statistical analysis was performed using descriptive statistics and IBM SPSS Statistics for Windows, V. 26.0 (IBM Corp., Armonk, NY, USA). Results The study found significant variability in the completeness of documentation. Patient demographics (age and name) were consistently recorded in 122 (100%) of the cases. However, critical data such as patient weight was recorded in only three (2.5%) of the forms, with 119 (97.5%) missing this information. Preoperative diagnoses were documented in one (0.8%) case, while 121 (99.2%) forms lacked this data. Preoperative vital signs were recorded in one (0.8%) case, with 120 (98.4%) missing them. Pre-medication prescriptions were noted in only two (1.6%) cases, leaving 120 (98.4%) incomplete. Conclusion The findings highlight substantial gaps in pre-anesthetic documentation. There is a pressing need for standardizing documentation practices to improve the quality and completeness of preoperative assessments.