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The anesthetic record: accuracy and completeness

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

Abstract

Purpose

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

Methods

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.

Results

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.

Conclusion

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.

Keywords

Medical Student Monit Physiological Variable Trend Function Anesthesia Record 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Résumé

Objectif

Évaluer si la formation en anesthésie et l’expérience influencent la tenue de dossier et son exactitude.

Méthode

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.

Résultats

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.

Conclusion

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.

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Copyright information

© Canadian Anesthesiologists 1999

Authors and Affiliations

  • J. Hugh Devitt
    • 3
    • 1
  • 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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