Does manual anaesthetic record capture remove clinically important data?

Schalkwyk, Johan M. van; Lowes, Damon A.; Frampton, Chris; Merry, Alan

doi:10.1093/bja/aer163

Cited by 32 publications

(17 citation statements)

References 13 publications

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“…This is likely to persist for a long time to come due to financial and technical challenges of implementing the electronic/computer based Anesthesia Information Management System despite the well documented superiority of the latter in literature. [3,17] The demographic data were 99-100% completed in all the audits except for the weight and height of patients. These are critical data in patients and staff 's identification and are usually available on many records including the operation list, operation checklist, patient case notes, operation and anesthesia registers, and are essential for other formalities including handing over and patient transfer.…”

Section: Discussionmentioning

confidence: 99%

The effect of teaching on the completeness of the anesthesia record charts for obstetric subarachnoid blocks in a low resource area hospital

Olateju

Adenekan

Owojuyigbe

2015

J Obstet Anaesth Crit Care

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Section: Discussionmentioning

confidence: 99%

The effect of teaching on the completeness of the anesthesia record charts for obstetric subarachnoid blocks in a low resource area hospital

Olateju

Adenekan

Owojuyigbe

2015

J Obstet Anaesth Crit Care

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“…It can facilitate effective monitoring of patients, vital medico-legal document and can serve as an important tool for audit, research, and quality improvement in anaesthesia service. All of these values depend on the accuracy of the record and type of recording (handwritten or electronic) [8].…”

Section: Discussionmentioning

confidence: 99%

Audit on Anaesthetic Record Completeness at A University Teaching Hospital Operation Theater of Low -Resource Setting, 2013

2017

JACCOA

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Background: Anaesthetic record is an essential part of the patient's medical record. It includes the perioperative management that is relevant to the anaesthesia practice. This information helps other staff who will be involved in the care of the patient, for medico-legal defense and for quality assurance. We sometimes found anaesthetic recording sheets with incomplete information during the postoperative visit of patients in the recovery room and on the wards in our hospital. We aimed to assess the level of anaesthetic record completeness. Methods:A cross-sectional study was conducted from February 18-March 18, 2013. All patients who were operated under anesthesia during the study period were included. A checklist developed based on our hospital anaesthetic sheet that used for data collection.Result: Hundred and twenty anaesthetic record sheets were audited. The name and time written consistently in local time were documented for all patients. The level of documentation was >90% for age, sex, date of operation, type of operation, medical history, physical examination, allergic history, medication history, consent, induction drugs with their dose, and maintenance drugs. However, the level of record completeness was < 50% for the content of consent, pre-induction vital signs, intraoperative vital signs, start and end of both anesthesia and surgery, type of regional anaesthesia, intraoperative blood loss, and order for postoperative management. Conclusion and recommendation:The level of anaesthetic record completeness was substandard in our hospital compared with the recommendations of WFSA and AAGBI. Training should be given for anaesthetists about the relevance of appropriate documentation for perioperative patient care. Furthermore, We suggest that clinical audit need to be carried out regularly in this hospital until the anaesthetist meet the standards, and in other similar settings in the country to know the magnitude of the problem and to establish strategies that may improve the practice of clinical record keeping.

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“…In terms of data quality, the manually recorded data clearly illustrated the human propensity to smoothen data. We have only succeeded in finding one scientific article mentioning this particular phenomenon pertaining to registration of time data,18 but many studies have demonstrated smoothing and inaccuracies in manually recorded medical data 19. Although this phenomenon impedes data quality, we are of the opinion that it is more likely that this reduction in data granularity would mask any differences rather than produce artificial ones between groups of differently timed TTAs.…”

Section: Discussionmentioning

confidence: 99%

What is optimal timing for trauma team alerts? A retrospective observational study of alert timing effects on the initial management of trauma patients

Lillebo¹,

Seim²,

Vinjevoll³

et al. 2012

JMDH

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BackgroundTrauma teams improve the initial management of trauma patients. Optimal timing of trauma alerts could improve team preparedness and performance while also limiting adverse ripple effects throughout the hospital. The purpose of this study was to evaluate how timing of trauma team activation and notification affects initial in-hospital management of trauma patients.MethodsData from a single hospital trauma care quality registry were matched with data from a trauma team alert log. The time from patient arrival to chest X-ray, and the emergency department length of stay were compared with the timing of trauma team activations and whether or not trauma team members received a preactivation notification.ResultsIn 2009, the trauma team was activated 352 times; 269 times met the inclusion criteria. There were statistically significant differences in time to chest X-ray for differently timed trauma team activations (P = 0.003). Median time to chest X-ray for teams activated 15–20 minutes prearrival was 5 minutes, and 8 minutes for teams activated <5 minutes before patient arrival. Timing had no effect on length of stay in the emergency department (P = 0.694). We found no effect of preactivation notification on time to chest X-ray (P = 0.474) or length of stay (P = 0.684).ConclusionProactive trauma team activation improved the initial management of trauma patients. Trauma teams should be activated prior to patient arrival.

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Does manual anaesthetic record capture remove clinically important data?

Abstract: In comparison with computerized record-keeping, manual record-keeping resulted in loss of clinically relevant information.

Cited by 32 publications

References 13 publications

The effect of teaching on the completeness of the anesthesia record charts for obstetric subarachnoid blocks in a low resource area hospital

The effect of teaching on the completeness of the anesthesia record charts for obstetric subarachnoid blocks in a low resource area hospital

Audit on Anaesthetic Record Completeness at A University Teaching Hospital Operation Theater of Low -Resource Setting, 2013

What is optimal timing for trauma team alerts? A retrospective observational study of alert timing effects on the initial management of trauma patients

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