Strengthening Perioperative Documentation: The ALCOA + approach in Obstetric Anaesthesia record keeping

Dr Nitesh Bargaje SAS; Dr Iwona Malkiewicz Consultant; Dr Marcus Hickson Consultant & Clinical Lead for Obstetric Anaesthesia
Bedfordshire Hospitals (Luton & Dunstable University Hospital

The RCoA QI initiative for improving anaesthetic chart documentation¹ deserves the implementation of data integrity principles³. The challenging task of incorporating consent, documentation of risk discussion, intraoperative record keeping, meticulous attention to time mapping of perioperative events and time-sensitive postoperative instructions has been attempted in this record. After approval from peers and the ethics committee, inputs were sought from midwives, recovery nurses and anaesthetists to develop this document to cover the complex details necessary for review, audit and research purposes. 

References: 1. Popescu M, Yap J, Improving anaesthetic chart documentation. Clin Med (Lond). 2022 Jul;22(Suppl 4):66-67. doi:10.7861/clinmed.22-4-s66. 2. Royal College of Anaesthetists. Raising the Standards: RCoA quality improvement compendium. 4th edition. London: RCoA, 2021   3. Rattan, Anil, Data Integrity: History, Issues, and Remediation of Issues PDA J Pharm Sci Technol. 2018 Mar-Apr;72(2):105-116