title: An observational study of the accuracy and completeness of an anesthesia information management system: recommendations for documentation system changes.
abstract: Anesthesia information management systems must often be tailored to fit the environment in which they are implemented. Extensive customization necessitates that systems be analyzed for both accuracy and completeness of documentation design to ensure that the final record is a true representation of practice. The purpose of this study was to determine the accuracy of a recently installed system in the capture of key perianesthesia data. This study used an observational design and was conducted using a convenience sample of nurse anesthetists. Observational data of the nurse anesthetists'delivery of anesthesia care were collected using a touch-screen tablet computer utilizing an Access database customized observational data collection tool. A questionnaire was also administered to these nurse anesthetists to assess perceived accuracy, completeness, and satisfaction with the electronic documentation system. The major sources of data not documented in the system were anesthesiologist presence (20%) and placement of intravenous lines (20%). The major sources of inaccuracies in documentation were gas flow rates (45%), medication administration times (30%), and documentation of neuromuscular function testing (20%)-all of the sources of inaccuracies were related to the use of charting templates that were not altered to reflect the actual interventions performed.
authors.affiliation: Author Affiliations: School of Nursing, The University of Alabama at Birmingham, AL, USA. bryan004@UAB.edu
authors.forename: Bryan A
authors.initials: BA
authors.lastname: Wilbanks
authors.forename: Jacqueline A
authors.initials: JA
authors.lastname: Moss
authors.forename: Eta S
authors.initials: ES
authors.lastname: Berner
mesh_terms: D000758:Anesthesia; D004282:Documentation; D007256:Information Systems / Q000458:organization & administration / Q000592:standards*; D007588:Job Satisfaction; D016347:Medical Records Systems, Computerized; D009740:Nursing Staff / Q000523:psychology; D009936:Organizational Innovation