Devitt J H, Rapanos T, Kurrek M, Cohen M M, Shaw M
Department of Anaesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
Can J Anaesth. 1999 Feb;46(2):122-8. doi: 10.1007/BF03012545.
To evaluate if anesthesia training and experience influenced chart completion and accuracy.
One hundred and twenty-four subjects, including medical students, anesthesia residents and community and university based clinical anesthesiologists, were given a standardized patient in a simulator environment and asked to conduct induction and maintenance of anaesthesia. Three critical events were introduced resulting in changes in BP, HR, PETCO2 and SpO2. Subjects were instructed to manage the patient and the anesthetic chart, as was their customary practice. Discrepancy, calculated as the difference between 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 four physiological variables of the three critical events, was compared across level of training, age of participants and number of years in practice.
The overall completeness of charting remained low (< 37%) with no relationship based on the anesthesiologist's age, level of training or number of years in practice. There was discrepancy in charting for all physiological variables (HR, BP, PETCO2 and SpO2, P < 0.0001), with a marked difference in the degree of discrepancy within each level of training. Training resulted in no differences in charting discrepancy.
Charting of data to the anesthetic record remained incomplete and inaccurate in all groups based on level of training, age and number of years in practice.
评估麻醉培训和经验是否会影响麻醉记录单的填写及准确性。
124名受试者，包括医学生、麻醉住院医师以及社区和大学附属医院的临床麻醉医生，在模拟环境中面对一名标准化患者，并被要求进行麻醉诱导和维持。引入三个关键事件，导致血压、心率、呼气末二氧化碳分压（PETCO2）和血氧饱和度（SpO2）发生变化。受试者被要求按照其惯常做法管理患者并填写麻醉记录单。差异定义为实际值与记录值之差除以实际生理值，通过双向重复测量方差分析（ANOVA），按培训水平比较所有四个生理变量的差异。麻醉记录单填写的完整性定义为在三个关键事件的四个生理变量中每个变量至少记录一个数据点，按培训水平、参与者年龄和从业年限进行比较。
麻醉记录单填写的总体完整性仍然较低（<37%），与麻醉医生的年龄、培训水平或从业年限无关。所有生理变量（心率、血压、PETCO2和SpO2，P<0.0001）的记录均存在差异，且每个培训水平内差异程度有显著不同。培训在记录差异方面未产生差异。
基于培训水平、年龄和从业年限，所有组在麻醉记录单上的数据填写仍然不完整且不准确。
