A randomized comparison between records made with an anesthesia information management system and by hand, and...

Anesthesia information management system (AIMS) technology is designed to facilitate high-quality anesthetic recordkeeping. We examined the hypothesis that no difference exists between AIMS and handwritten anesthetic records in regard to the completeness of important information contained as text data. We also investigated the effect of observational research on the completeness of anesthesiologists' recordkeeping.

As part of a larger randomized controlled trial, participants were randomized to produce 400 anesthetic records, either handwritten (n = 200) or using an AIMS (n = 200). Records were assessed against a 32-item checklist modified from a clinical guideline. Intravenous agent and bolus recordings were quantified, and data were compared between handwritten and AIMS records. Records produced with intensive research observation during the initial phase of the study (n = 200) were compared with records produced with reduced intensity observation during the final phase of the study (n = 200).

The AIMS records were more complete than the handwritten records (mean difference 7.1%; 95% confidence interval [CI] 5.6 to 8.6%; P < 0.0001), with higher completion rates for six individual items on the checklist (P < 0.0001). Drug annotation data were equal between arms. The records completed early in the study, during a period of more intense observation, were more thorough than subsequent records (87.3% vs 81.6%, respectively; mean difference 5.7%; 95% CI 4.2 to 7.3%; P < 0.0001).

The AIMS records were more complete than the handwritten records for 32 predefined items. The potential of observational research to influence professional behaviour in an anesthetic context was confirmed. This trial was registered at the Australian New Zealand Clinical Trials Registry No 12608000068369.