Documentation on the anesthetic record: correlation with clinically important variables

2006 ◽  
Vol 53 (11) ◽  
pp. 1086-1091 ◽  
Author(s):  
Michael J. Tessler ◽  
Athanasios Tsiodras ◽  
Kenneth J. Kardash ◽  
Ian Shrier
Keyword(s):  
Anesthetic Record

scholarly journals The anesthetic record: accuracy and completeness

1999 ◽  
Vol 46 (2) ◽  
pp. 122-128 ◽  
Author(s):  
J. Hugh Devitt ◽  
Theodore Rapanos ◽  
Matt Kurrek ◽  
Marsha M. Cohen ◽  
Melissa Shaw
Keyword(s):  
Anesthetic Record

Automated Anesthetic Record Keeping

1985 ◽  
pp. 147-161 ◽  
Author(s):  
N. Ty Smith
Keyword(s):  
Anesthetic Record ◽  
Record Keeping

ANESTHETIC RECORD COLOR

1943 ◽  
Vol 4 (3) ◽  
pp. 312-312
Author(s):  
Stuart C. Cullen
Keyword(s):  
Anesthetic Record

VCARS – veterinary computerized anesthetic record system

2005 ◽  
Vol 32 (4) ◽  
pp. 3
Author(s):  
JE Ilkiw ◽  
CM Brandt
Keyword(s):  
Record System ◽  
Anesthetic Record

WHY KEEP AN ANESTHETIC RECORD

1953 ◽  
Vol 14 (3) ◽  
pp. 311-313
Author(s):  
Eva Goddin Cutright
Keyword(s):  
Anesthetic Record

scholarly journals Assessing the completeness of perioperative anesthetic record documentation in a tertiary hospital

2020 ◽  
Vol 24 (6) ◽  
Author(s):  
Hayatul Akma Bolhan ◽  
Nurlia Yahya ◽  
Azarinah Izaham ◽  
Wan Rahiza Wan Mat ◽  
Raha Abdul Rahman ◽  
...  
Keyword(s):  
Prospective Observational Study ◽  
Tertiary Care ◽  
Tertiary Hospital ◽  
Policy Statement ◽  
Anesthetic Record ◽  
Standard Guideline ◽  
Tertiary Care Institution ◽  
American Society ◽  
American Society Of Anesthesiologists

Background and Objective: Many previous studies assessing the completeness of perioperative documentation of surgical patients were reported to be inadequate and unsatisfactory. The aim of this study was to compare the perioperative anesthetic record (PAR) at our tertiary care institution to a standard guideline and have an audit of its completeness. Methodology: It was a prospective, observational study, done in the general operating theater of Universiti Kebangsaan Malaysia Medical Centre (UKMMC). We compared our PAR to the American Society of Anesthesiologists (ASA) policy statement on documentation of anesthesia care. We audited the completeness of PAR documentation of 358 patients by using a self-generated checklist which was created in accordance to the PAR parameters. A total of 44 parameters were studied covering three phases; preoperative, peroperative and post-operative phases. Results: Although the UKMMC PAR varied from the ASA guidelines, various salient parameters were identical in both. None of the perioperative forms were completely filled throughout the three perioperative phases. Out of 44 parameters studied, only 2 parameters were completely filled, which were medications administered and fluid therapy. Conclusion: Parameters given in the UKMMC PAR varied with the ASA guidelines and the documentation was found to be only partially complete. Hence, necessary modification of the current PAR in our institution, and the stress on filling it completely is needed to improve the quality of perioperative anesthetic documentation. Keywords: Audit; Completeness; Perioperative; Anesthetic record; Documentation Citation: Bolhan HA, Yahya N, Izaham A, Mat WRW, Rahman RA, Musthafa QA. Anaesth. pain intensive care 2020;24(6):--- Received: 23 April 2020, Reviewed: 17 August 2020, Revised: 18 October 2020, Accepted: 27 October 2020

Scheduling and Auditing of Anesthetic Record using Personal Computer

1989 ◽  
Vol 22 (2) ◽  
pp. 205
Author(s):  
Soon Jae Kim ◽  
Hyun Soo Kim ◽  
Kwang Min Kim ◽  
Byung Jo Choi
Keyword(s):  
Personal Computer ◽  
Anesthetic Record

The automated anesthetic record is inevitable and valuable

1990 ◽  
Vol 6 (4) ◽  
pp. 333-334 ◽  
Author(s):  
William K. Hamilton
Keyword(s):  
Anesthetic Record

The automated anesthetic record will not automatically solve problems in record keeping

1990 ◽  
Vol 6 (4) ◽  
pp. 334-337 ◽  
Author(s):  
Reynolds J. Saunders
Keyword(s):  
Anesthetic Record ◽  
Record Keeping

Automated Documentation Error Detection and Notification Improves Anesthesia Billing Performance

2007 ◽  
Vol 106 (1) ◽  
pp. 157-163 ◽  
Author(s):  
Stephen F. Spring ◽  
Warren S. Sandberg ◽  
Shaji Anupama ◽  
John L. Walsh ◽  
William D. Driscoll ◽  
...  
Keyword(s):  
Median Time ◽  
Error Detection ◽  
Computer Software ◽  
Information Management System ◽  
Timely Manner ◽  
Anesthetic Record ◽  
Record Keeping ◽  
Before And After ◽  
Order Of Magnitude ◽  
E Mail

Background Documentation of key times and events is required to obtain reimbursement for anesthesia services. The authors installed an information management system to improve record keeping and billing performance but found that a significant number of their records still could not be billed in a timely manner, and some records were never billed at all because they contained documentation errors. Methods Computer software was developed that automatically examines electronic anesthetic records and alerts clinicians to documentation errors by alphanumeric page and e-mail. The software's efficacy was determined retrospectively by comparing billing performance before and after its implementation. Staff satisfaction with the software was assessed by survey. Results After implementation of this software, the percentage of anesthetic records that could never be billed declined from 1.31% to 0.04%, and the median time to correct documentation errors decreased from 33 days to 3 days. The average time to release an anesthetic record to the billing service decreased from 3.0+/-0.1 days to 1.1+/-0.2 days. More than 90% of staff found the system to be helpful and easier to use than the previous manual process for error detection and notification. Conclusion This system allowed the authors to reduce the median time to correct documentation errors and the number of anesthetic records that were never billed by at least an order of magnitude. The authors estimate that these improvements increased their department's revenue by approximately $400,000 per year.

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