Table 2 Assessment of perioperative records over a period of 18 months
Standard: | 1st Audit | 2nd Audit | 3rd Audit | ||||||
|---|---|---|---|---|---|---|---|---|---|
Paper records | Electronic records | Electronic records with proforma | |||||||
Electronic | Vs Paper | Proforma | Vs Paper | Vs Electronic | |||||
n (%) | n (%) | Absolute change (%) | p-value | n (%) | Absolute change (%) | p-value | Absolute change(%) | p-value | |
Name & signature noted | 38 (76) | 23 (100) | + 24 | 0.008 | 26 (100) | + 24 | 0.006 | – | – |
Type of consent recorded | 28 (56) | 22 (96) | + 40 | < 0.001 | 26 (100) | + 44 | < 0.001 | + 4 | 0.469 |
WHO checklist Completed | 43 (86) | 9 (39) | −47 | < 0.001 | 26 (100) | + 14 | 0.088 | + 17 | < 0.001 |
Medications administered | 32 (64) | 15 (65) | + 1 | 1.000 | 19 (73) | + 9 | 0.606 | + 8 | 0.757 |
Puncture site noted | 49 (98) | 21 (91) | −7 | 0.232 | 26 (100) | + 2 | 1.000 | + 9 | 0.215 |
Complications recorded | 27 (54) | 14 (61) | + 7 | 0.621 | 25 (96) | + 42 | < 0.001 | + 35 | 0.003 |
Legibility of records | 43 (86) | 23 (100) | + 14 | 0.090 | 26 (100) | + 14 | 0.088 | – | – |
Vital monitoring recorded | 49 (98) | 1 (4) | − 94 | < 0.001 | 24 (92) | −6 | 0.268 | + 88 | < 0.001 |
Bed rest instructions | 50 (100) | 16 (70) | − 30 | < 0.001 | 26 (100) | – | – | + 30 | 0.003 |
Puncture site instructions | 48 (96) | 2 (9) | −93 | < 0.001 | 25 (96) | – | 1.000 | + 87 | < 0.001 |
Distal pulse instructions | 48 (96) | 1 (4) | −92 | < 0.001 | 23 (88) | −8 | 0.331 | + 84 | < 0.001 |
Anti-coagulation regime | 27 (54) | 15 (65) | + 11 | 0.449 | 21 (81) | + 27 | 0.026 | + 16 | 0.332 |
Oral Intake instructions | 47 (94) | 1 (4) | −90 | < 0.001 | 23 (88) | −6 | 0.406 | + 84 | < 0.001 |
Follow-up plans | 12 (24) | 15 (65) | + 41 | 0.001 | 14 (54) | + 30 | 0.012 | −11 | 0.562 |
Total | 50 (100) | 23 (100) | 26 (100) | ||||||