Assessment of Compliance and Completeness of Anesthetic Records at the University Clinics of Lubumbashi: Implications for Quality and Patient Safety

Abstract

The objective of this study was to assess the compliance and completeness of anesthetic records at the University Clinics of Lubumbashi, while evaluating their impact on quality of care and patient safety. A descriptive cross-sectional study was conducted between January and June 2023, including a sample of 150 anesthetic records. Evaluation criteria encompassed the completeness of required information (pre-anesthetic assessment, intraoperative monitoring, incident documentation, and postoperative follow-up) as well as adherence to the recommendations established by the American Society of Anesthesiologists (ASA). The results revealed variability in completeness across different sections, with a high level of documentation observed in the intraoperative section (75%), whereas significant gaps were noted in the postoperative documentation (38%). Furthermore, overall compliance with ASA recommendations was achieved in only 61% of cases. These findings underscore the urgent need to strengthen anesthetic documentation in order to enhance patient safety.