Why the study?
Preoperative evaluation gives an in-depth view of patient's clinical condition and helps match the mode of anesthesia, prompting an assessment of documentation quality in pre-anesthesia assessment forms.
Cross-Sectional (n=293)
No
This clinical audit demonstrates an acceptable overall completion rate of preanesthesia assessment forms, though specific areas like age, past medical history, and fasting status require improved documentation.
Gaps in pre-anesthesia documentation merit attention; this Level 5 audit leaves open effects on perioperative outcomes.
Background: Preoperative evaluation (PAE) gives in-depth view of patient’s clinical condition and helps match mode of anesthesia accordingly. This study was planned to assess the quality of documentation in pre-anesthesia assessment form (PAAF) completed during preoperative assessment. Methodology: This descriptive study was conducted at Pakistan Kidney and Liver Institute and Research Center (PKLI & RC) Lahore. Pre-Anesthesia assessment forms of patients operated from 1st January to 31st December 2019 were reviewed. A 22-components modified Global Quality Index (GQI) was used to assess the quality of PAAF. Descriptive statistical analysis was performed using SPSS version 25. Results: Completion was excellent (100 %) in only one indicator; eighteen indicators had an acceptable completion rate (90-99 %) while three indicators were completed in < 90 % PAAF. Consent was the only component complete in 100% PAAF. Documentation of age (25%), past medical history (89.4%) and fasting status (88.4%) were the least documented aspects of PAAF. The average completion rate was 93.5 ± 5.2 % and all 22 indicators of GQI were completed in 14.3% PAAF. Conclusion: Our audit shows that majority of PAAF are complete and all its components have been well documented. Only few elements were not recorded in some PAAS. Further education and audit will be required to achieve complete documentation. Key words: Preanesthesia assessment; Preoperative evaluation; Documentation; Global Quality Index Citation: Shahzad S, Younas T, Khan EUD. Clinical audit on quality of preanesthesia evaluation. Anaesth. pain intensive care 2021;25(1):15-18; DOI: 10.35975/apic.v25i1.1429 Received: 31 October 2020, Reviewed: 22 December 2020, Accepted: 23 December 2020
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Shahzad et al. (2021) conducted a cross-sectional in Patients undergoing surgery requiring preanesthesia evaluation (n=293). Pre-anesthesia assessment form (PAAF) documentation was evaluated on Overall percentage completion of the pre-anesthesia assessment form based on a 22-component modified Global Quality Index.
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