Overview of Anesthesia Report Documentation in The Central Surgical Installation

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Published Apr 21, 2026
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Vol. 1 No. 1 (2026): January-April

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D.P. Eka Noviani
Anasthesiology Diploma, Institute of Technology and Health Bali, Denpasar, Bali, Indonesia
Ni luh Putu Inca Buntari Agustini
Master of Nursing, Institute of Technology and Health Bali, Denpasar, Bali, Indonesia
Ni Luh Putu Lusiana Devi
Anasthesiology Diploma, Institute of Technology and Health Bali, Denpasar, Bali, Indonesia

Abstract

Background: The completeness of the anesthesia report is very important as an indicator of patient safety. However, the anesthesia report was still found to be incomplete. Comprehensive anesthesia report recording at pre-, intra-, and post-anesthesia is required. This study aims to determine the description of documenting pre-anesthesia, intra-anesthesia, and post-anesthesia reports.


Methods: This research method used descriptive research with a cross-sectional approach. The sample consisted of 249 surgical case anesthesia report forms taken using a convenience sampling technique. The research instrument uses a check list to assess the completeness of anesthesia report documentation. The collected data was analyzed using univariate analysis.   


Result: The results of this study showed that the majority of anesthesia reports were for elective surgery (69%), with general surgery as the dominant surgical category (31%). The majority of pre-anesthesia (71%), intra-anesthesia (98%), and post-anesthesia report documentation (97%) were included in the complete category. However, in the pre-anesthesia report, there were deficiencies in the assessment of laboratory results such as hemoglobin, hematocrit, platelets, urinalysis, electrolytes, others, and a list of problems and diagnoses. Overall, 70% of anesthesia reports were filled out completely.     


Conclusion: The research conclusion is that the majority of pre, intra, and post anesthesia reports fall into the complete category. However, improvements are needed in the documentation of laboratory items. It is hoped that there will be regular socialization and monitoring to improve the quality of anesthesia report documentation.

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