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The anaesthetic record: a confidential survey on data omission or modification
D C Galletly1, W L Rowe, R S Henderson
1Section of Anaesthesia, Wellington School of Medicine, New Zealand.
Anaesthesia and Intensive Care
|February 1, 1991
Summary
Fifty-five percent of surveyed anaesthetists in New Zealand admitted to occasionally altering or omitting data from anaesthetic records. Dissatisfaction with record forms was linked to this data manipulation.
Area of Science:
- Medical Practice
- Anaesthesiology
- Patient Safety
Background:
- Anaesthetic records are crucial for patient care and medical-legal documentation.
- Understanding data integrity in anaesthetic records is vital for quality assurance.
Purpose of the Study:
- To determine the prevalence of data omission or falsification in anaesthetic records.
- To identify factors associated with intentional data manipulation by anaesthetists.
Main Methods:
- A confidential survey was distributed to anaesthetists in New Zealand.
- 245 active anaesthetists responded to the survey regarding their practices.
Main Results:
- 55% of respondents reported occasional omission or falsification of physiological data.
- Intentional data manipulation correlated with dissatisfaction with record forms and perceived intraoperative distraction.
- No correlation was found between data manipulation and medicolegal concerns.
Conclusions:
- A significant proportion of anaesthetists engage in data manipulation of anaesthetic records.
- Improving anaesthetic record forms may reduce data integrity issues.
- The perceived importance of records for future anaesthetists influences data accuracy.