Documentation of care is an important part of medical treatment. In the present health care environment, increased emphasis on documentation is a result of the requirements of third-party payers, both private and governmental. Many factors affect the quality of documentation, such as ease of use of forms, provider interest, and the availability of information. Good documentation may help improve patient care by easing the transfer of information from one provider to another. A review of reports from the Australian Incident Monitoring Study suggested that improvements in information exchange would help prevent at least some of the incidents reported. Other researchers have found that essential elements of the preanesthesia assessment are frequently missing from notes. Several studies have examined the influence of the electronic record on accuracy, vigilance, or workload of charting in the intraoperative period. However, little work has been done on the influence of the design of the preoperative evaluation tool on necessary data collection. In this study, we examined the configuration of a standardized preoperative anesthesia form to determine its effect on documentation of representative elements of the preanesthesia assessment.
Available at: http://works.bepress.com/alan_marco/86/