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      Perioperative anesthetic documentation: Adherence to current Australian guidelines

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          Abstract

          Purpose:

          The lack of adequate perioperative documentation has legal implications and can potentially affect the quality and safety of patient care. Despite the presence of guidelines, the adequacy of perioperative documentation in Australasia has not been adequately assessed. The aim of this study is to assess the adequacy of anesthetic documentation on the pre and intraoperative encounters and to test the hypotheses that documentation is incomplete in the settings of emergency vs. elective procedures, regional vs. general anesthesia, and manual vs. electronic documentation.

          Materials and Methods:

          The study was an observational retrospective study in the setting of a 250-bed teaching hospital in metropolitan Adelaide, Australia. The perioperative records of 850 patients were analyzed. A scoring system was designed, based on a policy statement from the Australian and New Zealand College of Anesthetists and a survey of the hospital anesthetists. Scored and categorical data was analyzed using Chi-square test. Numerical data was analyzed using student t-test. The null hypothesis was accepted or rejected at 0.05 significance.

          Results:

          There were significant deficiencies in the adequacy of preanesthetic and intraoperative records. This has been shown to be true in all cases. Documentation was found to be poorer in the emergency setting when compared to elective cases (median scores 15 vs. 21 P = 0.03) as well as documentation of airway assessment for cases done solely under regional anesthesia (42 vs. 85%, P = 0.05). There were no significant differences in the adequacy of electronic vs. manual records ( P = 0.92).

          Conclusion:

          There are significant deficiencies in the adequacy of perioperative records. This has been shown to be true in all cases, but is especially so in emergency cases and for patients having only regional anesthesia.

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          Most cited references 22

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          Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review.

          Developers of health care software have attributed improvements in patient care to these applications. As with any health care intervention, such claims require confirmation in clinical trials. To review controlled trials assessing the effects of computerized clinical decision support systems (CDSSs) and to identify study characteristics predicting benefit. We updated our earlier reviews by searching the MEDLINE, EMBASE, Cochrane Library, Inspec, and ISI databases and consulting reference lists through September 2004. Authors of 64 primary studies confirmed data or provided additional information. We included randomized and nonrandomized controlled trials that evaluated the effect of a CDSS compared with care provided without a CDSS on practitioner performance or patient outcomes. Teams of 2 reviewers independently abstracted data on methods, setting, CDSS and patient characteristics, and outcomes. One hundred studies met our inclusion criteria. The number and methodologic quality of studies improved over time. The CDSS improved practitioner performance in 62 (64%) of the 97 studies assessing this outcome, including 4 (40%) of 10 diagnostic systems, 16 (76%) of 21 reminder systems, 23 (62%) of 37 disease management systems, and 19 (66%) of 29 drug-dosing or prescribing systems. Fifty-two trials assessed 1 or more patient outcomes, of which 7 trials (13%) reported improvements. Improved practitioner performance was associated with CDSSs that automatically prompted users compared with requiring users to activate the system (success in 73% of trials vs 47%; P = .02) and studies in which the authors also developed the CDSS software compared with studies in which the authors were not the developers (74% success vs 28%; respectively, P = .001). Many CDSSs improve practitioner performance. To date, the effects on patient outcomes remain understudied and, when studied, inconsistent.
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            An observational study of anesthesia record completeness using an anesthesia information management system.

            Studies of the accuracy and completeness of handwritten anesthesia records demonstrate deficiencies in documentation, suggesting that the quality of anesthesia records can be improved.
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              An audit of anaesthetic record keeping

               M. RAFF,  MFM James,  M Raff (2003)
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                Author and article information

                Journal
                J Anaesthesiol Clin Pharmacol
                J Anaesthesiol Clin Pharmacol
                JOACP
                Journal of Anaesthesiology, Clinical Pharmacology
                Medknow Publications & Media Pvt Ltd (India )
                0970-9185
                2231-2730
                Apr-Jun 2013
                : 29
                : 2
                : 211-215
                Affiliations
                Department of Anaesthesia, Queen Elizabeth Hospital/Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, South Australia, Australia
                [1 ]Department of Anaesthesia, Lyell McEwin Hospital, South Australia, Australia
                [2 ]School of Medicine, Flinders University, South Australia, Australia
                Author notes
                Address for correspondence: Dr. Islam Elhalawani, Department of Anesthesia, Queen Elizabeth Hospital, 28 Woodville Road, Woodville West, South Australia-5011, Australia. E-mail: islam.elhalawani@ 123456adelaide.edu.au
                Article
                JOACP-29-211
                10.4103/0970-9185.111726
                3713670
                23878444
                Copyright: © Journal of Anaesthesiology Clinical Pharmacology

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Categories
                Original Article

                Anesthesiology & Pain management

                regional, anesthesia, documentation, electronic, emergency

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