A Comparison of Electronic and Handwritten Anaesthetic Records for Completeness of Information‪.‬

The anaesthetic record is an essential component of every episode of anaesthesia care, the requirements for which, for practice in Australia and New Zealand, are outlined in the Australian and New Zealand College of Anaesthetists' Professional Document PS6 (1). Similar guidelines are also produced by the Royal College of Anaesthetists (2) and the American Society of Anesthesiologists (3). A complete record is valuable, primarily as an accurate guide to immediate and subsequent patient management, but it also contains data that have an important role in research and quality assurance (4-8). Furthermore, complete records have important medicolegal implications (9-12) and an expanding role in costing and billing calculations (13-15). Traditionally, anaesthetists have used handwritten records, however a number of publications have found these to be frequently inaccurate, incomplete and illegible (16-21). Furthermore, in a confidential survey of New Zealand anaesthetists, nearly half admitted to intentionally altering or omitting observations and events (22).