Completeness of Pre‐Anaesthetic Assessment Documentation—Paper Versus Electronic Medical Record: Audit of Compliance With Current Australian Guidelines

Background 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. Methods 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. Results 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. Conclusion 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 .