Arterial blood pressure and heart rate discrepancies between handwritten and computerized anesthesia records.
Previous publications suggest that handwritten anesthesia records are less accurate when compared with computer-generated records, but these studies were limited by small sample size, unblinded study design, and unpaired statistical comparisons. Eighty-one pairs of handwritten and computer-generated neurosurgical anesthesia records were retrospectively compared by using a matched sample design. Systolic arterial pressure (SAP), diastolic arterial pressure (DAP), and heart rate (HR) data for each 5-min interval were transcribed from handwritten records. In computerized records, the median of up to 20 values was calculated for SAP, DAP, and HR for each consecutive 5-min epoch. The peak, trough, standard deviation, median, and absolute value of the fractional rate of change between adjacent 5-min epochs were calculated for each case. Pairwise comparisons were performed by using Wilcoxon tests. For SAP, DAP, and HR, the handwritten record peak, standard deviation, and fractional rate of change were less than, and the trough and median were larger than, those in corresponding computer records (all with P: < 0.05, except DAP median and HR peak). Considering together all the recorded measurements from all cases, extreme values were recorded more frequently in computerized records than in the handwritten records.


CONCLUSIONS
The discrepancies between handwritten and computerized anesthesia records suggest that some of the data in handwritten records are inaccurate. The potential for inaccuracy should be considered when handwritten records are used as source material for research, quality assurance, and medicolegal purposes.
Reich
D L
DL
Departments of Anesthesiology and Biomathematical Sciences, Mount Sinai School of Medicine, New York, NY 10029-6574, USA. david.reich@mssm.edu
Wood
R K
RK
Mattar
R
R
Krol
M
M
Adams
D C
DC
Hossain
S
S
Bodian
C A
CA
D000293:Adolescent; D000328:Adult; D000368:Aged; D000758:Anesthesia; D001794:Blood Pressure / Q000502:physiology*; D002648:Child; D002675:Child, Preschool; D006339:Heart Rate / Q000502:physiology*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008499:Medical Records; D016347:Medical Records Systems, Computerized; D008875:Middle Aged; D019635:Neurosurgical Procedures; D012189:Retrospective Studies