The anesthetic record: accuracy and completeness

Purpose: 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 anesthesio logists, were given a standardized patient in a simulator environment and a sked to conduct induction and maintenance of anaesthesia. Three critical ev ents were introduced resulting in changes in BP, HR, PETCO2 and SpO(2). Sub jects were instructed to manage the patient and the anesthetic chart, as wa s their customary practice, Discrepancy, calculated as the difference betwe en 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 f our physiological variables of the three critical events, was compared acro ss level of training, age of participants and number of years in practice, Results: The overall completeness of charting remained low (<37%) with no r elationship based on the anesthesiologist's age, level of training or numbe r of years in practice. There was discrepancy in charting for all physiolog ical variables (HR, BP, PETCO2 and SpO(2), P < 0.0001), with a marked diffe rence 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 a nd inaccurate in all groups based on level of training, age and number of y ears in practice.