Completeness and Accuracy of Electronic Anesthesia Record in Neurological institute of Thailand

Abstract

Anesthesia record is a medical record for recording the anesthetic procedure and events that occur during the anesthesia administration process. However, there is still lack of evidence to support the completeness and accuracy of the automatic electronic anesthesia record. For clinical usage purposes, users are required to fill out the necessary detail manually. The purpose of this research is to identify the problems and gaps that lead to the incompleteness and inaccuracy of the automatic electronic anesthesia record within the Neurological Institute of Thailand. This research is based on the 5-year datasets, between the electronic and the manual recording process. This is in accordance with American Association of Nurse Anesthetists (AANA) and American Society of Anesthesiologists (ASA) for the completeness and accuracy of information. Datasets were analyzed by quantitative statistics method. A total of 400 records were used. The result showed that for pre-operative, the completeness was found to be at 341 records (85.3%) with the accuracy of 212 records (53.0%). For the record intra-operative, the result showed that the completeness of the record was found to be at 311 records (77.8%) with the accuracy of 238 records (59.5%) and post-operative process the completeness was found to be at 354 records (88.5%) with the accuracy of 337 records (84.3%). The most complete and accurate subsection records were 400 records (100%) of ASA physical status from the pre-operative process and 400 records (100%) of physiologic monitoring data from intra-operative process. Usual events during intra-operative process showed with the least complete with 355 records (88.8%) and lowest accuracy with 342 records (85.5%). These findings will lead to the development software and training in the use of electronic recording