Auckland City Hospital, P/Bag 92024, Auckland 1023, New Zealand.
Br J Anaesth. 2011 Oct;107(4):546-52. doi: 10.1093/bja/aer163. Epub 2011 Jun 10.
Numerous studies have shown smoothing and inaccuracies in handwritten anaesthetic records, but the clinical relevance of these findings is unclear. We therefore sought to determine whether the behaviour of anaesthetists differed in assessing anaesthetic records re-synthesized from either handwritten or automated records.
In a recent New Zealand study (ACTRN12608000068369), both manual and automated records were acquired from the same anaesthetics. Manual records were digitized using digital callipers. Selected data (systolic, diastolic, and mean arterial pressure; heart rate; Sp(O(2)); E'(CO(2))) were replayed in a computerized anaesthetic record-keeping system with which the participants were familiar, to present manual and corresponding automated anaesthetic records. Ten anaesthetists, randomly selected from participants in this study, assessed 24 replayed records (a manual and an automated record from each of 10 anaesthetics, with two of each displayed twice). They indicated where and how they would have intervened if administering these anaesthetics. We compared the number of interventions for each pair of anaesthetics and subjective measures of anaesthetic quality.
In our selected sample of unstable anaesthetics, the mean (SD) number of interventions per anaesthetic was 4.0 (2.9) vs 5.2 (3.4) for manual and automated records, respectively (P=0.013). Subjective measures did not differ significantly between record types. Assessors identified 32 artifacts in six manual records (0.32/record assessment) and 105 artifacts in eight automated records (1.05/record assessment), P=0.14. Replicability was moderate (COV 39.8%).
In comparison with computerized record-keeping, manual record-keeping resulted in loss of clinically relevant information.
许多研究表明手写麻醉记录存在平滑和不准确的问题，但这些发现的临床相关性尚不清楚。因此，我们试图确定麻醉师在评估从手写或自动记录重新合成的麻醉记录时的行为是否存在差异。
在最近的一项新西兰研究（ACTRN12608000068369）中，从同一名麻醉师那里同时获取了手动和自动记录。手动记录使用数字卡尺进行数字化。选择的数据（收缩压、舒张压和平均动脉压；心率；Sp(O(2))；E'(CO(2)))在参与者熟悉的计算机化麻醉记录系统中回放，以呈现手动和相应的自动麻醉记录。从这项研究的参与者中随机选择了 10 名麻醉师，评估了 24 个回放记录（每个麻醉师的一个手动和一个自动记录，每个记录显示两次）。他们指出如果进行这些麻醉，他们将在哪里以及如何进行干预。我们比较了每对麻醉记录的干预次数和麻醉质量的主观测量。
在我们选择的不稳定麻醉样本中，每例麻醉的平均（SD）干预次数分别为手动记录 4.0（2.9）和自动记录 5.2（3.4）（P=0.013）。记录类型之间的主观测量没有显著差异。评估者在六份手动记录中发现了 32 个伪影（每份记录评估 0.32），在八份自动记录中发现了 105 个伪影（每份记录评估 1.05），P=0.14。可重复性中等（COV 39.8%）。
与计算机记录保存相比，手动记录保存导致丧失了临床相关信息。
