title: Agreement on sedation-related events between a procedural sedation registry and computerized medical records.
abstract: OBJECTIVE
  Little is known about the accuracy of the medical record to document sedation-related events (SREs). Our hypotheses were that, when compared to a reference database (RD), a procedural sedation quality assurance registry (PSQAR) and medical records were accurate documentation of SREs.
  
  
  METHODS
  All cases in our PSQAR over 13 months were examined. Those with SREs were entered into the RD. We reviewed the computerized medical record (CMR; both physician documentation and nursing documentation) to determine the presence of procedural sedation notes and documentation of SRE.
  
  
  RESULTS
  A total of 203 sedation cases were entered into the PSQAR. The RD consisted of 74 SREs during 60 cases. The PSQAR included 61 (82%) of 74 events (95% confidence interval [CI], 72%-90%), whereas the CMR included 44 (60%) of 74 events (95% CI, 47%-71%). Physician documentation completely matched the RD in 12 (20%) 60 cases (95% CI, 11-32) and nursing documentation completely matched the RD in 24 (40%) of 60 cases (95% CI, 28-53). Physician and nursing documentation were complete and agreed with each other in only 4 (9%) of 60 cases (95% CI, 2-16; kappa = 0.13).
  
  
  CONCLUSIONS
  When compared to the RD, the accuracy of the PSQAR was very good. However, the accuracy of the CMR, including both nursing and physician documentation, was poor and there was poor agreement between them. This has implications for chart review-based research and quality improvement.
authors.affiliation: Department of Emergency Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM 87131-0001, USA.
authors.forename: Kyle
authors.initials: K
authors.lastname: Shaver
authors.forename: Steven
authors.initials: S
authors.lastname: Weiss
authors.forename: Darren
authors.initials: D
authors.lastname: Braude
mesh_terms: D016292:Procedural Sedation / Q000009:adverse effects*; D004282:Documentation / Q000592:standards*; D005568:Forms and Records Control / Q000592:standards*; D006801:Humans; D016347:Medical Records Systems, Computerized / Q000592:standards*; D010865:Pilot Projects; D011446:Prospective Studies; D011785:Quality Assurance, Health Care; D012042:Registries / Q000592:standards*; D014193:Trauma Centers / Q000706:statistics & numerical data*