Completeness of Pre-Anaesthetic Assessment Documentation-Paper Versus Electronic Medical Record: Audit of Compliance...

Electronic medical records possess numerous benefits over paper-based systems, aiming to enhance patient safety and quality of care by improving accessibility, legibility and comprehensiveness of documentation. There is a lack of local literature specifically examining paper vs. electronic documentation with regard to completeness of the pre-anaesthetic assessment record, as assessed against current standards.

Pre-anaesthetic assessment documentation for adult patients presenting to preadmissions clinic prior to elective surgery at a 590-bed tertiary hospital in Adelaide, South Australia was retrospectively examined. In total, 268 paper-based records and 163 electronic records were analysed. Standards outlined by the Australian and New Zealand College of Anaesthetists (ANZCA) were used to develop a 17-item scoring system, with each item scored as either not documented, incomplete or complete.

The median completeness score for paper-based records was 28.3/34 points (83%) compared to 26.9/34 points (79%) for electronic records (p < 0.001). High-scoring items, including patient identifiers, date of review and anaesthetist name, were largely automatically transferred into the electronic chart, or filled in by nurses on the paper records. Less than 1% of all records were judged to be fully complete in their documentation.

Introduction of electronic pre-anaesthetic assessment records was associated with a significant decrease in completeness of documentation, despite the benefits of enhanced legibility and auto-filled data fields. The majority of both paper and electronic records failed to achieve 100% compliance with standards outlined by ANZCA.