title: A comparison of electronic and handwritten anaesthetic records for completeness of information.
abstract: Complete documentation in anaesthetic records is important for patient management, research and quality assurance and has medicolegal implications. This study compares the completeness of information contained in electronic versus handwritten intraoperative anaesthetic records. A sample of 70 handwritten records was randomly selected from anaesthesia performed in the month prior to implementation of the Integrated Injectable Drug Administration and Automated Anaesthesia Record System and compared to a similar sample of electronic records generated eight months later. A comprehensive scoring system, based on the Australian and New Zealand College of Anaesthetists' guideline PS6, was used to compare the completeness of information throughout the entire intraoperative record. There was no significant difference in the total score for completeness between electronic (78%) and handwritten (83%) records (P = 0.16). Handwritten records were more complete with respect to weight (P < 0.0001), American Society of Anesthesiologists' physical status score (P < 0.0001), the size and type of artificial airway used (P = 0.003) and a record of the surgeons involved (P = 0.0004). Electronic records were more complete with respect to a record of drug administration including intravenous drugs (P < 0.0001), vapour (P = 0.0001) and nitrous oxide/oxygen (P < 0.0001), a record of end-tidal carbon dioxide monitoring (P = 0.006) and the level of trainee supervision (P = 0.0002). There was no overall difference in the completeness of electronic versus handwritten records. Several differences did exist however, highlighting both clinically important advantages and deficiencies in the electronic system. Records from both systems sometimes lacked important information.
authors.affiliation: Department of Anaesthesia, Starship Children's Hospital, Auckland, New Zealand.
authors.forename: W A G
authors.initials: WA
authors.lastname: Wrightson
mesh_terms: D000758:Anesthesia; D005260:Female; D006236:Handwriting; D006751:Hospital Information Systems; D006801:Humans; D008297:Male; D008499:Medical Records; D016347:Medical Records Systems, Computerized