The anesthetic record: accuracy and completeness

Abstract

RRTPurpose: 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 BP, HR, PETCO~ and SpOt. 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, BP, PETCO 2 and SpO v 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.Objectff: I~valuer si la formation en anesth~sie et rexp&ience influencent la tenue de dossier et son exactitude. M~.thode 9 Cent vingt-quatre sujets, y compris des &udiants en mEdecine, des residents en anesth&ie et des anesth&iologistes de pratique priv& ou universitaire ont regu le modEle d'un patient dans un environnement simulE et on leur a demandE de procEder ~ rinduction et ~ rentretien de I'anesth&ie. On a introduit trois incidents critiques impliquant des changements de TA, FC, PFrCO 2 et SpO v On a demanda aux sujets de procEder ~. I'anesth&ie et de remplir le dossier comme ils avaient I'habitude de le faire. La discordance, calcul& ~ partir de la difference entre les valeurs rEelles et celles du dossier divisEe par la valeur physiologique veritable, &ait comparEe sur la base du niveau de formation selon une analyse de variance (ANOVA pour valeurs rEp&Ees) pour les quatre variables physiologiques. Le dossier complet, dEflni par renregistrement d'au moins une donn& pour chacune des variables physiologiques des trois incidents critiques, Etait compare selon le niveau de formation, I'~ge des participants et le nombre d'annEes d'exp&ience. l~.sultats : I'ach~vement global du dossier a EtE faible (<37 %) et ne pr&entait pas de differences bas&s sur I'~ge, la formation ou le nombre d'ann~es de pratique. II y avait des divergences d'inscription au dossier pour toutes les ...

An audit of anaesthetic record keeping

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