Introduction: The quality of electronic anesthesia documentation is important for downstream communication and to demonstrate appropriate diligence to care. Documentation quality will also impact the success of reimbursement contracts that require timely and complete documentation of specific interventions. We implemented a system to improve completeness of clinical documentation and evaluated the results over time.
Methods: We used custom software to continuously scan for missing clinical documentation during anesthesia. We used patient allergies as a test case, taking advantage of a unique requirement in our system that allergies be manually entered into the electronic record. If no allergy information was entered within 15 min of the "start of anesthesia care" event, a one-time prompt was sent via pager to the person performing the anesthetic. We tabulated the daily fraction of cases missing allergy data for the 6 mo before activating the alert system. We then obtained the same data for the subsequent 9 mo. We tested for systematic performance changes using statistical process control methodologies.
Results: Before initiating the alert system, the fraction of charts without an allergy comment was slightly more than 30%. This decreased to about 8% after initiating the alerts, and was significantly different from baseline within 5 days. Improvement lasted for the duration of the trial. Paging was suspended on nights, weekends, and holidays, yet weekend documentation performance also improved, indicating that weekday reminders had far-reaching effects.
Discussion: Electronic anesthesia documentation performance can be rapidly managed and improved by using an automatic process monitoring and alerting system.