Documentation on the anesthetic record: Correlation with clinically important variables.

摘要

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 < or = 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 formswere 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.