Audit on documentation completeness after regional nerve blocks at University of Gondar referral hospital, 2018

Abstract

Documentation after regional nerve block is an essential component of patient pain management. It will safeguard against medico legal issues, it will increase the successful performance of regional anesthesia, to safely follow patients having nerve block, to improve patient’s recall of risks and benefits, to get briefed information during hand over of pain management and to request written rather than verbal communication during hand over of pain management. However, there are no specified protocols which should be recorded for each individual nerve block, less adequate documentation form and there is interpersonal variation during documentation here in this setup. So, we aimed to determine whether regional nerve block documentation trends in University of Gondar referral hospital meet the standards or not. Methods: A cross sectional study is conducted from February 1-May 30, 2018.All patients who were given regional nerve block for postoperative pain management in the study period were included. A checklist used for data collection is prepared based on NYSORA Guideline recommendations. Results: Forty-four record sheets were audited after patient’s exposure of regional nerve block. The aseptic technique was documented for all patients. The level of documentation was >85% for name of the nerve block and the availability of standard monitoring. However, the level of completeness of documentation was done below 50% for signature of service provider, consent, attempts of the technique, length of the procedure, approach of the nerve block, size of the needle, site of the block, time out period and level of sedation and indication of the nerve block. Conclusion and recommendation: The level of documentation after regional nerve block was unsatisfactory in our hospital compared with the recommendations of NYSORA guideline. So training should be given for all anesthetists who will be involved in regional nerve block and regular re auditing should be done to attain the given standards.