Anaesthetists’ records of pre‐operative assessment

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Abstract
The pre‐operative anaesthetic records of 195 patients were analysed for the presence of 12 agreed core items of pre‐operative assessment. This study showed that anaesthetists recorded 26.8 per cent of this information. In up to one‐third of patients the following were recorded: smoking history, family history, gastro‐oesophageal reflux, airway assessment, dental assessment, chest examination, heart‐sounds and blood pressure. Previous anaesthesia, drug history and allergies were recorded in one to two‐thirds of patients. Past medical history was recorded in over two‐thirds of patients. With a view to improving the level of record‐keeping, a formatted, pre‐printed pre‐operative assessment record was introduced into practice and two months later the audit was repeated. A small but non‐significant improvement in record keeping was observed. An argument is made for the introduction of an interdisciplinary, unified anaesthetic pre‐operative record.

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