Assessing anesthetic indexes in patient's medical records

Anesthesia information about pre anesthesia events demonstrates the patients’ status and care provided to them. It can be used as a source of detection of diseases and legal judgments. This study aimed at assessing quality of anesthetic records of patients admitted to the operating rooms of Besat hospital of Sanandaj. This descriptive study evaluate anesthesia records of patients that undergone operation in Besat hospital of Sanandaj in 2011. Four hundred records selected by systematic random sampling and quality of recording anesthesia data’s in patients records were evaluated by using a checklist. Survey data’s were analyzed using SPSS software and descriptive statistics including frequency, ratio and mean. The results showed that basic patient information in the 10.7%, preoperative diagnosis and suggested operation in 34.4%, preoperative medication in 22%, operation time in 100% and used anesthesia drugs in 14.5% of cases were not listed. Information about the complications of anesthesia was recorded only in 2% of forms and name and volume of fluid intake wasn’t totally recorded in 42.8% of forms. Information contained in the anesthesia forms of patients who are undergone surgery in Besat hospital of Sanandaj is incomplete. Evaluating the causes of defects and attempt to resolve the causes can help to improve medical education, and ability of documents files with the goals of education, research and legal.