Analysis of noteworthy indicators on the anesthesia record: a prospective, multiregional study.
A national sample of anesthesia records were studied prospectively for the presence or absence of predetermined, noteworthy record indicators judged important in documenting a basic core of information describing the monitoring and care provided in a generic clinical setting. Only records involving the administration of a volatile anesthetic for the purpose of achieving general anesthesia, prepared by providers with at least 6 months of experience in anesthesia care were examined. No identifying patient, provider, or institutional data were recorded. Indicators were scored in a "present/absent" format. All data were pooled; the goal was to describe the overall phenomena in terms of frequency of compliance. A total of 4,989 anesthesia records were evaluated in terms of 13 record indicators. Those missed ranged from 0.0% (patient identification) to 28.6% (notation regarding emergence). Ten were omitted on less than 6% of the records: 3 (surgery and/or anesthesia start time, notation regarding emergence, surgical positioning noted) were omitted on more han 13.0% of the records. Given he observed inconsistencies, perhaps the anesthesia record needs redesign or the rationale behind documentation requires increased emphasis in educational and equally assurance programs.
Biddle
C
C
Virginia Commonwealth University, Richmond, Va., USA.
Bauer
L
L
Dosch
M
M
Dove
C
C
Nagelhout
J
J
Waugaman
W
W
Zaglaniczny
K
K
D000758:Anesthesia; D000768:Anesthesia, General / Q000592:standards; D005568:Forms and Records Control; D006801:Humans; D008499:Medical Records / Q000592:standards*; D016343:Monitoring, Intraoperative; D011446:Prospective Studies; D019984:Quality Indicators, Health Care / Q000592:standards*