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AUDIT OF DOCUMENTATION OF REGIONAL ANAESTHESIA-ANALGESIA AT A TERTIARY CHILDREN'S HOSPITAL IN THE UNITED KINGDOM
ESRA Academy. Miller T. Sep 8, 2016; 138223; 0040 Topic: Miscellaneous Complications/ Medicolegal
Dr. Tamryn Miller
Dr. Tamryn Miller

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Abstract
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Background and Aims:

The accurate documentation of clinical interventions and management is of the upmost importance in modern medicine. The audit sought to benchmark the current quality of documentation at a tertiary children’s hospital in UK against the Royal College of Anaesthetists’ good practice guidelines on documentation of regional anaesthesia-analgesia procedures.

Methods:

The data was collected retrospectively over 5 months from the electronic patient records. Information was gathered on documentation of consent details for regional analgesia, procedural details and legibility.

Results:

Data was collected on 227 regional analgesia procedures. Consent for regional analgesia was recorded only in 70.5% patients. There were 23 types of regional analgesia procedures performed. The documentation of discussed complications for regional analgesia was very low e.g. nerve injury (28%), failure (26%) and introduction of infection (26%).

The majority of anesthetists did not document the procedural details of regional analgesia. Legibility was suboptimal in 43.2% of anaesthetic records.

Conclusions:

The regional analgesia documentation practice is sub-optimal and heterogenous amongst the anaesthetists within the hospital. The recommendations include the need for education on the good practice standards of documentation of regional analgesia to ensure better institutional quality and robust medico-legal cover. We also recommend a standardised national regional anaesthesia-analgesia documentation form.

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