Computerized patient anesthesia records: less time and better quality than manually produced anesthesia records

Abstract

Study objective: To compare manual and computerized anesthesia information management systems (AIMS's) with respect to time demands on the anesthetist and record quality.

Design: Videotaped clinical anesthesia cases were independently reviewed along with the records produced.

Setting: Private practice anesthesia at a 150-bed community hospital.

Patients: Ten consecutive ASA physical status I patients having video arthroscopy of the knee by the same surgeon and having general anesthesia.

Interventions: One anesthetist recorded six cases: three with the computer and three manually. Two more anesthetists each recorded two cases: one with the computer and one manually.

Measurements and main results: The proportion of the anesthetist's time spent on the documentation for the computer records was significantly less than that spent on manual records (14.9% vs. 36.6%; p < 0.001). Nevertheless, significantly more vital sign data points were recorded on the computer than on the manual records (245.2 vs. 45.0 vital sign points per case; p < 0.001), as well as significantly more notes and drug information (61.0 vs. 40.0 notes per case; p < 0.02). The computer record was always legible, but this was not the case with the manual records. There was no significant difference in the number of artifacts detected on the records.

Conclusion: The concern that the introduction of computerized AIMS's may complicate the anesthesia working environment by requiring more time than manual AIMS's and thus detracting from direct patient care is not supported by this study. In fact, this computer approach not only required less time but also produced a more complete and higher-quality record than did the manual AIMS.