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Documentation on the anesthetic record: correlation with clinically important variables

[Documentation sur le dossier anesthésique : corrélation avec les variables cliniques importantes]
  • Michael J. Tessler
  • Athanasios Tsiodras
  • Kenneth J. Kardash
  • Ian Shrier
Journal of anesthesia

Abstract

Purpose

A survey was undertaken at a single Academic Health Sciences Centre to document the opinions of anesthesiologists regarding what variables are important to document on the anesthetic record. A subsequent chart review of anesthetic records was undertaken to determine the extent to which these anesthesiologists record the variables they consider important.

Methods

A survey form was mailed to all practicing staff anesthesiologists at the four adult McGill University affiliated hospitals. Anesthesiologists were asked to rank 23 preoperative and 33 intraoperative variables on a scale from 1-5: (1 = essential; 2 = important; 3 = useful; 4 = not important; 5 = excessive information). All variables considered by consensus ≤ 2 (important to essential) were then assessed as to whether they were recorded on 60 charts randomly selected from each of the four teaching hospitals. Only anesthetic records completed by staff anesthesiologists were evaluated.

Results

Ninety percent (47/52) of survey forms were completed and returned. Preoperative variables considered most important to document included examination of the patient’s airway and allergy status. Intraoperative variables considered most important for documentation were the patient’s vital signs. The only variable to have been recorded on all the anesthetic records was the anesthesiologist’s name. The allergy status was the most recorded preoperative variable (84% of charts). The recording rates of intraoperative variables ranged from 100% (anesthesiologist’s name, start time of anesthesia) to 24% (estimated blood loss).

Conclusion

McGill anesthesiologists consider many preoperative and intraoperative variables to be important to document on the anesthetic record. However, subsequent chart review indicated that many of these variables are recorded inconsistently. The transmission of anesthesia-related medical information might be improved if anesthesiologists recorded more consistently information they consider to be important.

Objectif

Une enquête a été menée à un Centre universitaire de sciences de la santé pour connaître les opinions des anesthésiologistes sur les variables jugées importantes à inscrire au dossier anesthésique. Une revue subséquente des dossiers anesthésiques a été réalisée pour vérifier si les anesthésiologistes enregistrent les variables qu’ils considèrent importantes.

Méthode

Un formulaire d’enquête a été posté à tous les anesthésiologistes en exercice dans les quatre hôpitaux pour adultes affiliés à l’université McGill. On leur a demandé de coter 23 variables préopératoires et 33 peropératoires sur une échelle de 1-5: (1 = essentielle, 2 = importante, 3 = utile, 4 = non importante et 5 = surinformation). Toutes les variables reconnues par la majorité ≤ 2 (importante à essentielle) ont été ensuite vérifiées pour savoir si elles étaient enregistrées dans 60 dossiers choisis au hasard dans chacun des quatre hôpitaux d’enseignement. Seuls les dossiers anesthésiques remplis par des spécialistes en service ont été évalués.

Résultats

Des formulaires envoyés 90 % (47/52) ont été remplis et retournés. Les variables préopératoires considérées importantes comprenaient l’examen des voies aériennes du patient et la présence d’allergie. Les variables peropératoires prioritaires ont été les signes vitaux des patients. La seule variable enregistrée dans tous les dossiers a été le nom de l’anesthésiologiste. La présence d’allergie a été la variable préopératoire la plus souvent enregistrée (84 % des dossiers). Les taux d’enregistrement des variables peropératoires allait de 100 % (nom de l’anesthésiologiste, heure du début de l’anesthésie) à 24 % (perte sanguine estimée).

Conclusion

Les anesthésiologistes de McGill considèrent que de nombreuses variables préopératoires et peropératoires sont importantes à noter au dossier anesthésique. Une revue subséquente des dossiers a indiqué que beaucoup de ces variables ne sont pas constamment inscrites. La transmission des informations médicales liées à l’anesthésie serait améliorée si les anesthésiologistes notaient plus régulièrement les variables qu’ils jugent les plus importantes.

Keywords

Survey Form Preoperative Variable Anesthesia Record Anesthetic Record Staff Anesthesiologist 
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.

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Copyright information

© Canadian Anesthesiologists 2006

Authors and Affiliations

  • Michael J. Tessler
    • 1
  • Athanasios Tsiodras
    • 1
  • Kenneth J. Kardash
    • 1
  • Ian Shrier
    • 2
  1. 1.Department of AnesthesiaSMBD- Jewish General HospitalMontrealCanada
  2. 2.Department of Community and EpidemiologySir Mortimer B. Davis - Jewish General Hospital and McGill UniversityMontrealCanada

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