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* From the Departments of Anesthesia, and
Community and Epidemiology, Sir Mortimer B. Davis - Jewish General Hospital and McGill University, Montreal, Quebec, Canada.
Address correspondence to: Dr. Michael J Tessler, Department of Anesthesia, Room A-335, SMBD- Jewish General Hospital, 3755 Cote Ste Catherine Road, Montreal, Quebec H3T 1E2, Canada. Phone: 514-340-8222, ext. 5701; Fax: 514-340-8108; E-mail: mtessler{at}ana.jgh.mcgill.ca
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Abstract |
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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.
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Introduction |
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The Canadian Anesthesiologists’ Society (CAS) has guidelines defining the perioperative variables to be recorded.2 These include charting all monitored physiologic variables, oxygen saturation, and end-tidal carbon dioxide (CO2) when appropriate. Reasons for deviation from these guidelines are to be documented.2 Further, the anesthesia record should include the patient’s level of consciousness, heart rate, blood pressure, oxygen saturation and respiratory rate as first determined in the postanesthesia care unit.2 Admittedly, some anesthesiologists may not necessarily agree with all components of these guidelines. However, anesthesiologists must consider which variables are important to document as a reflection of the care provided. This study was undertaken to determine the thoroughness of the anesthetic record keeping at a major Academic Health Sciences Centre. This was accomplished by first determining which variables were considered by faculty members to be important for documenting on the preoperative and intraoperative chart. This was followed by a review of a random sampling of patient records to determine the extent to which the identified important variables were recorded.
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Methods |
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If a survey form was not returned within approximately one month, the non-responding anesthesiologist was contacted and reminded to complete and return the survey. Each anesthesiologist who had still not returned a completed survey was subsequently asked in person to return a completed form. In an attempt to maximize the response rate and ensure completeness of the documentation, the covering letter accompanying the original survey form stated that it was the intention of the authors to submit the results in consideration for publication.
The survey form consisted of a section for the preoperative record and one for the intraoperative record. All variables were ranked on a five point scale (1–5): 1 = essential information; 2 = important information; 3 = useful information; 4 = not important information; and 5 = excessive information.
The surveys were then collected and the corresponding mean and SD were calculated for each of the variables. Thereafter, 60 patient records from each of the four hospitals (n = 240 in total), were evaluated to assess the extent to which those variables with a mean score 2.00 were recorded. Charts were selected randomly from the same year as the survey. The analysis was restricted to patient records where the anesthesia care was administered by a staff anesthesiologist. The staff were not made aware of the survey results prior to the analysis of the records. Whenever anesthesia residents were in attendance the anesthetic record was excluded from the database. Any record completed by an anesthesiologist who was not based at that hospital was also excluded. Finally, anesthetic records for electroconvulsive therapy or continuous epidural analgesia during labour were excluded. Almost any mark in the relevant location on the anesthetic record was considered as being completed and variables were considered as being either complete (1), not complete (2), or unknown (3). In the latter case, that variable was not included in the summary data. For example, if there was no mark in the appropriate location for allergy, this was counted as "not complete", even if the patient had no allergies. Alternatively, the intraoperative use of central venous pressure (CVP) monitoring could not always be deduced, so that if no mark was present to indicate the presence of a CVP line for a major intra-abdominal procedure, a score of 3 was assigned.
The survey results were analyzed using standard descriptive statistics and each variable surveyed is expressed as mean ± SD. The proportion of charts with complete information for variables considered important by anesthesiologists (defined as mean 2.00) was calculated by dividing the "number of charts with documentation" by the "total number of charts".
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Results |
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2.00). Variables considered most important on the preoperative assessment were airway (1.02 ± 0.15) and allergies (1.02 ± 0.15). The variable most frequently charted on the preoperative record was the presence of an allergy (84% of charts). The variable least often recorded, of those variables considered important to document, was exercise tolerance (2% of charts; Table I
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Discussion |
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We are the first to investigate the records of anesthesiologists who were surveyed as to what variables they view to be important on the anesthetic record. Others have shown that anesthesiologists could improve their record keeping.3–8 We were generous in giving credit to the anesthesiologist as having recorded a preoperative variable, even if the documentation was only a mark, without any clear explanation. The documented completion rate for examination of the airway, for example, might have been considerably lower had the survey evaluated the importance of specific airway characteristics (such as mouth opening, temperomandibular distance and dentition). The analysis was limited to the anesthetic records of staff anesthesiologists and excluded charts of cases where an anesthesia resident was present. In the province of Québec, registered respiratory therapists can contribute to documentation on the intraoperative record, so certain elements of the intraoperative record might have included notation of a therapist’s charting on the anesthetic record. Interestingly, even though anesthesiologists are remunerated, in part, on the basis of time units, some of the anesthetic records (13 of 240) failed to have the finishing time documented.
A range of opinions was anticipated regarding the relative importance of certain variables included in the survey. For example, exercise tolerance might be a particular phrase used by a minority of anesthesiologists and would not be expected to be recorded on most anesthetic records. However, we were interested in any indication of cardio-respiratory reserve on the preanesthetic chart, and found a minority of charts where this item was documented. Further, we included certain variables we thought to be excessive (e.g., name of operating room nurse in charge) and our survey results bore out this supposition. Alternatively, we were surprised to observe that some anesthesiologists consider variables such as oxygen saturation or patient vital signs on the intraoperative record to be important but not essential, and the patient’s ASA score was not rated < 2, on average. We observed a 100% completion rate for one variable, the anesthesiologist’s name. However, the anesthesiologist’s name was the variable used to verify that a staff anesthesiologist, working without a resident, provided the anesthetic. A missing anesthesiologist’s name would have resulted in exclusion of that record from the data base.
The anesthetic records assessed at the four McGill University hospitals have different formats. This difference could have influenced the documentation rate.8,9 However, none of the anesthetic groups audited had complete documentation of all the variables assessed. Combining the best features of each and standardizing the form across the hospitals might improve the overall completion rate.8
There is a growing body of literature assessing the role of computerized anesthesia records which suggest the hand-written anesthesia intraoperative record to be biased and inaccurate.10,11 We made no attempt to verify charting accuracy. However, we acknowledge that, depending on the computerized system involved, intraoperative documentation would be more complete.
There are several limitations regarding the survey and the chart review. The survey is limited by several factors including a modest sample size and evaluating a group from a single health sciences centre.12 However, the overall response rate (90%) was high. Moreover, the authors proposed a broad range of preoperative and intraoperative variables to the anesthesiologists at a large Canadian anesthesia program to determine which were considered important to document. We chose to use a rating score 2 as the cut-off for documentation because it was our view that this level of implied importance should be documented. We did not assess all variables that some anesthesiologists consider important to record. Given the range of recording of the variables assessed, those variables with consensus scores > 2 would probably have had lower rates of documentation. A further limitation of our study design is that we did not compare the charts of individual anesthesiologists to their ranking of the variables on the survey. However, we limited our analysis to those variables considered important by consensus, and it is our view that those variables represent the minimum of what should be recorded. We also assessed the same number of charts from each of the four teaching hospitals. However, each institution has a different number of anesthesiologists. Hence, more charts were reviewed per anesthesiologist at the Montreal Neurological Institute than any of the other sites.
In conclusion, McGill anesthesiologists consider many preoperative and intraoperative variables to be important to document on the anesthesia record. However, chart auditing documented that these variables were not consistently recorded. The transmission of patient care information would be improved if anesthesiologists consistently recorded those variables they view to be important for documentation purposes.
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Acknowledgments |
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Footnotes |
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This material was presented in part at the 62nd annual meeting of the Canadian Anesthesiologists’ Society, in Toronto, Ontario June 2006.
Accepted for publication July 7, 2006. Revision accepted August 14, 2006.
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References |
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2 Canadian Anesthesiologists’ Society. Guidelines to the practice of anesthesia. Revised 2005. Supplement to the Canadian Journal of Anesthesia. Available from URL; http:www.cas.ca/members/sign_in/guidelines/practice_of_anesthesia.
3 Devitt JH, Rapanos T, Kurrek M, Cohen MM, Shaw M. The anesthetic record: accuracy and completeness. Can J Anesth 1999: 46; 122–8.
4 Kluger MT, Tham EJ, Coleman NA, Runciman WB, Bullock MF. Inadequate pre-operative evaluation and preparation: a review of 197 reports from the Australian Incident Monitoring Study. Anaesthesia 2000: 55; 1173–8.[Medline]
5 Roach VJ, Lau TK, Kee WD, Wormald PJ. Perioperative documentation: are we doing enough? Aust NZ Obstet Gynaecol 1998; 38: 166–9.
6 Rahman K, Jenkins JG. Failed tracheal intubation in obstetrics: no more frequent but still managed badly. Anaesthesia 2005; 60: 168–71.[Medline]
7 Rowe L, Galletly DC, Henderson RS. Accuracy of text entries within a manually compiled anaesthetic record. Br J Anaesth 1992; 68: 381–7.
8 Ausset S, Bouaziz H, Brosseau M, Kinirons B, Benhamou D. Improvement of information gained from the pre-anaesthetic visit through a quality-assurance programme. Br J Anaesth 2002; 88: 280–3.
9 Marco AP, Buchman D, Lancz C. Influence of form structure on the anesthesia preoperative evaluation. J Clin Anesth 2003; 15: 411–7.[Medline]
10 Reich DL, Wood RK Jr, Mattar R, et al. Arterial blood pressure and heart rate discrepancies between handwritten and computerized anesthesia records. Anesth Analg 2000; 91: 612–6.
11 Hollenberg JP, Pirraglia PA, Williams-Russo P, et al. Computerized data collection in the operating room during coronary artery bypass surgery: a comparison to the hand-written anesthesia record. J Cardiothorac Vasc Anesth 1997; 11: 545–51.[Medline]
12 Todd MM, Burmeister LF. Principles of successful sample surveys (Editorial). Anesthesiology 2003; 99: 1251–2.[Medline]
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