The anesthetic record: accuracy and completeness

  • J. Hugh DevittEmail author
  • Theodore Rapanos
  • Matt Kurrek
  • Marsha M. Cohen
  • Melissa Shaw
Reports of Investigation



To evaluate if anesthesia training and experience influenced chart completion and accuracy.


One hundred and twenty-four subjects, including medical students, anesthesia residents and community and university based clinical anesthesiologists, were given a standardized patient in a simulator environment and asked to conduct induction and maintenance of anaesthesia. Three critical events were introduced resulting in changes in BR HR, PETCO2 and SpO2. Subjects were instructed to manage the patient and the anesthetic chart, as was their customary practice. Discrepancy, calculated as the difference between the actual and charted values divided by the actual physiological value was compared by level of training with a two-way repeated measures analysis of variance (ANOVA) for all four physiological variables. The completeness of charting, defined as at least one data point recorded for each of the four physiological variables of the three critical events, was compared across level of training, age of participants and number of years in practice.


The overall completeness of charting remained low (< 37%) with no relationship based on the anesthesiologist’s age, level of training or number of years in practice. There was discrepancy in charting for all physiological variables (HR, BR PETCO2 and SpO2, P < 0.0001), with a marked difference in the degree of discrepancy within each level of training. Training resulted in no differences in charting discrepancy.


Charting of data to the anesthetic record remained incomplete and inaccurate in all groups based on level of training, age and number of years in practice.


Medical Student Monit Physiological Variable Trend Function Anesthesia Record 
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Évaluer si la formation en anesthésie et l’expérience influencent la tenue de dossier et son exactitude.


Cent vingt-quatre sujets, y compris des étudiants en médecine, des résidents en anesthésie et des anesthésiologistes de pratique privée ou universitaire ont reçu le modèle d’un patient dans un environnement simulé et on leur a demandé de procéder à l’induction et à l’entretien de l’anesthésie. On a introduit trois incidents critiques impliquant des changements de TA, FC, PETCO2 et SpO2. On a demandé aux sujets de procéder à l’anesthésie et de remplir le dossier comme ils avaient l’habitude de le faire. La discordance, calculée à partir de la différence entre les valeurs réelles et celles du dossier divisée par la valeur physiologique véritable, était comparée sur la base du niveau de formation selon une analyse de variance (ANOVA pour valeurs répétées) pour les quatre variables physiologiques. Le dossier complet, défini par l’enregistrement d’au moins une donnée pour chacune des variables physiologiques des trois incidents critiques, était comparé selon le niveau de formation, l’âge des participants et le nombre d’années d’expérience.


Lachèvement global du dossier a été faible (< 37 %) et ne présentait pas de différences basées sur l’âge, la formation ou le nombre d’années de pratique. Il y avait des divergences d’inscription au dossier pour toutes les variables physiologiques (HR, BR PETCO2 et SpO2, P < 0,0001), avec une nette différence dans le degré de divergence pour chaque niveau de formation. La formation n’a pas eu d’influence sur la discordance dans le dossier.


Lentrée des données au dossier anesthésique était incomplète et inexacte dans tous les groupes basés sur le niveau de formation, l’âge et le nombre d’années d’expérience.


  1. 1.
    Klocke H, Trispel S, Rau G, Hatzky U, Daub D. An anesthesia information system for monitoring and record keeping during surgical anesthesia. J Clin Monit 1986; 2: 246–61.PubMedCrossRefGoogle Scholar
  2. 2.
    Schneider AJL, Kreul JF, Zollinger RM Jr. Patient monitoring in the operating room — an anesthetist’s viewpoint. Med Instrum 1976; 10: 105–9.PubMedGoogle Scholar
  3. 3.
    Weinger MB, Englund CE. Ergonomic and human factors affecting anesthetic vigilance and monitoring performance in the operating room environment. Anesthesiology 1990; 73: 995–1021.PubMedCrossRefGoogle Scholar
  4. 4.
    Edsall DW. Computerization of anesthesia information management — users’ perspective. J Clin Monit 1991; 7: 351–8.PubMedCrossRefGoogle Scholar
  5. 5.
    Cook RI, McDonald JS, Nunziata E. Differences between handwritten and automatic blood pressure records. Anesthesiology 1989; 71: 385–90.PubMedCrossRefGoogle Scholar
  6. 6.
    Kroll DA. The automated record: legal help or Pandora’s box? J Clin Monit 1991; 7: 77–8.Google Scholar
  7. 7.
    Devitt JH, Kurrek MM, Cohen MM, et al. Testing the raters: inter-rater reliability of standardized anaesthesia simulator performance. Can J Anaesth 1997; 44: 924–8.PubMedCrossRefGoogle Scholar
  8. 8.
    Block FE Jr. Normal fluctuation of physiologic cardiovascular variables during anesthesia and the phenomenon of “smoothing”. J Clin Monit 1991; 7: 141–5.PubMedCrossRefGoogle Scholar
  9. 9.
    Lerou JGC, Dirksen R, van Daele M, Nijhuis GMM, Crul JF. Automated charting of physiological variables in anesthesia: a quantitative comparison of automated versus handwritten anesthesia records. J Clin Monit 1988; 4: 37–47.PubMedCrossRefGoogle Scholar
  10. 10.
    Byrne AJ, Sellen AJ, Jones JG. Errors on anaesthetic record charts as a measure of anaesthetic performance during simulated critical incidents. Br J Anaesth 1998; 80: 58–62.PubMedGoogle Scholar
  11. 11.
    Cohen MM, Duncan PG, Tate RB. Does anesthesia contribute to operative mortality? JAMA 1988; 260: 2859–63.PubMedCrossRefGoogle Scholar
  12. 12.
    Lanza V. Automatic record keeping in anaesthesia — a nine-year Italian experience. Int J Clin Monit Comput 1996; 13: 35–43.PubMedCrossRefGoogle Scholar
  13. 13.
    Cohen MM, Duncan PG, Pope WDB, Wolkenstein C. A survey of 112,000 anaesthetics at one teaching hospital (1975–83). Can Anaesth Soc J 1986; 33: 22–31.PubMedCrossRefGoogle Scholar

Copyright information

© Canadian Anesthesiologists 1999

Authors and Affiliations

  • J. Hugh Devitt
    • 3
    • 1
    Email author
  • Theodore Rapanos
    • 3
    • 1
  • Matt Kurrek
    • 3
    • 1
  • Marsha M. Cohen
    • 3
    • 1
    • 2
  • Melissa Shaw
    • 3
  1. 1.Department of AnaesthesiaSunnybrook Health Sciences Centre, University of TorontoCanada
  2. 2.Centre for Research in Women’s HealthUniversity of TorontoCanada
  3. 3.Department of Health Science AdministrationUniversity of TorontoCanada

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