title: Accuracy of Vasopressor Documentation in Anesthesia Records.
abstract: OBJECTIVE
  To determine the accuracy of documentation of vasoactive medication administration in anesthetic records.
  
  
  METHODS
  Cross-sectional observational study.
  
  
  METHODS
  Single academic center.
  
  
  METHODS
  Attending and resident anesthesiologists.
  
  
  METHODS
  None.
  
  
  RESULTS
  An auditor inspected the anesthesia worktop between cases looking for partially used syringes of vasopressors, and the anesthesia record for the preceding case was reviewed for entries related to administration of these agents. In 100 anesthesia records for cases in which a phenylephrine and/or ephedrine bolus was apparently administered, 26% (95% CI: 18-35%) had full documentation and 36% (95% CI: 27-46%) had no documentation. In the 38% of cases that had partial documentation, a median of 50% (interquartile range 33%, 67%) of the total amounts given were documented.
  
  
  CONCLUSIONS
  The authors found complete or partial omission of documentation of bolus doses of vasopressors in anesthesia records in the majority of cases in which such drugs were given. This finding has the potential to jeopardize the data integrity of local and pooled case registries and conclusions of retrospective studies that utilize these data.
authors.affiliation: Department of Anesthesiology, Mount Sinai School of Medicine. Electronic address: david.wax@mssm.edu.
authors.forename: David B
authors.initials: DB
authors.lastname: Wax
authors.affiliation: New York University, New York, NY.
authors.forename: Justin B
authors.initials: JB
authors.lastname: Feit
mesh_terms: D000758:Anesthesia; D003430:Cross-Sectional Studies; D004282:Documentation; D004809:Ephedrine / Q000008:administration & dosage; D006801:Humans; D010656:Phenylephrine / Q000008:administration & dosage; D014662:Vasoconstrictor Agents / Q000008:administration & dosage*
chemical_list: D014662:Vasoconstrictor Agents; D010656:Phenylephrine; D004809:Ephedrine
keywords: anesthesia information management system; documentation; vasopressors