title: Diversity in preoperative-assessment data collection, a literature review.
abstract: The appropriate anesthetic techniques and care during and after operation rely on data gathered during the preoperative assessment. Because various people are involved, standardization of this process is important. This paper provides a systematic literature review about which data items are collected in the preoperative assessment. Thirty-two relevant articles were found by PubMed search. To categorize data SNOMED CT concepts are used, resulting in 13 categories totaling 540 data items. The two largest categories of data were "past history of clinical finding", and "physical examination procedure" with 251 and 75 data items respectively. Our study showed a high diversity of data items in the preoperative assessment. Because of the diversity of patients and treatment options available one undisputed preoperative assessment data set is hard to define. However, to solve the problem of exchangeability of the information at least anesthesiologists should use a same core set of data.
authors.affiliation: Dept. of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands. l.ahmadian@amc.uva.nl
authors.forename: Leila
authors.initials: L
authors.lastname: Ahmadian
authors.forename: Ronald
authors.initials: R
authors.lastname: Cornet
authors.forename: Wilton A
authors.initials: WA
authors.lastname: van Klei
authors.forename: Nicolette F
authors.initials: NF
authors.lastname: de Keizer
mesh_terms: D000776:Anesthesiology; D003625:Data Collection / Q000592:standards*; D003955:Diagnostic Tests, Routine / Q000592:standards*; D008487:Medical History Taking / Q000592:standards*; D016347:Medical Records Systems, Computerized / Q000592:standards*; D009870:Operating Room Information Systems / Q000592:standards*; D011300:Preoperative Care; D011785:Quality Assurance, Health Care / Q000592:standards