Auditing the medico‐legal aspects of notekeeping for Caesarean section

In the UK, obstetric surgery is commonly performed with the patient awake and her partner present. Patient expectations are high. Even under high quality regional anaesthesia, non‐painful sensation may occur. This and other contentious issues must be discussed before surgery. Legal proceedings against obstetric anaesthetists are rare, but may arise many months later. Accurate contemporaneous notes are essential. The quality of notekeeping was audited for 50 Caesarean sections. A redesigned anaesthetic chart with prompts for key information was introduced and the audit repeated. There were significant improvements in documenting the pre‐operative discussion of: intra‐operative sensation; conversion to general anaesthesia; post‐dural puncture headache; suppositories; neuraxial opiate‐induced itch. Records of pain free operations; the presence or absence of nerve root pain; and the timing of events leading to delivery were significantly increased. This audit suggests that an anaesthetic chart with specific prompts improves the documentation of medico‐legally relevant information.