Incomplete Medical Records After Major Surgery
Documentation of clinical review and vital signs following major surgery is commonly incomplete, according to an article in the latest issue of the Medical Journal of Australia.
Dr Forbes McGain, an anaesthetist and intensivist from Melbourne's Western Hospital, and his co-authors conducted a retrospective audit of medical records of 211 adult patients who had undergone major surgery in five hospitals over a two-year period to July 2005.
During the first three post-operative days on the ward, 83 per cent of medical records had incomplete documentation of vital signs and clinical reviews by doctors and nurses.
"Numerous studies have shown that severe inhospital adverse events, such as cardiac arrest and unexpected death, are frequently preceded by abnormal vital signs," with an abnormal respiratory rate being the most accurate predictor.
However, the study found that respiratory rate was the most commonly undocumented observation (15.4 per cent). Vital signs were more commonly undocumented in patients without epidural or patient-controlled (PC) analgesia, during evening nursing shifts, and during successive post-operative days on the ward.
Nursing review was most commonly undocumented in the evening and for patients without epidural or PC analgesia. Medical review was more commonly unrecorded on weekends. There was also notable variation between the five hospitals.
Dr McGain said it was possible that staff did actually review patients but failed to document it because of time restraints or forgetfulness. "However, it seems unlikely that this could account for all the incomplete documentation."
Despite the incompleteness of documentation, mortality rates were low. "Such documentation is a record of human activity and does not represent a therapeutic intervention; its absence does not necessarily imply a lack of attention to patient care. However, if a culture of limited documentation is applied to higher-risk patients … it may have appreciable negative consequences," he said.
The researchers comment that further research is needed to understand the reasons for this systematic failure and to develop strategies to improve post-operative documentation of observations and review of patients.
CONTACT: Dr Forbes McGain (on request only)
Kylie Walker (AMA) 02 6270 5471 or 0405 229 152