Debra Buchman | PubMed Health

PubMed2003

Influence of form structure on the anesthesia preoperative evaluation.

STUDY OBJECTIVE: To determine the impact of changes in form design on the capture of administrative and clinical data elements. DESIGN: Randomized retrospective chart review. SETTING: Academic health center. PATIENTS: Patients undergoing surgical procedures in the operating rooms at Medical College Hospital. INTERVENTION: The principal intervention was the implementation of a newly designed anesthesiology preoperative evaluation form with the intent to improve data capture. MEASUREMENTS: Charts were reviewed for the presence or absence of the following indicators: Addressograph Stamp, Proposed Surgery, Current Medications, Medication Doses/Frequency, Allergies, ASA Physical Status, Anesthesia Plan, Attending Note, and fasting (NPO) Status. MAIN RESULTS: Completion of Proposed Surgery and ASA Physical Status was lower for the structured form. Completion of Attending Notes was higher with the new form. Medication Doses were more often completed, but they remained below desired levels on the new form. CONCLUSIONS: Design of a form can have a significant impact on the completion rate of form elements. Visual cues such as a labeled space for medication doses may improve the completion of these elements. Design layout can also have an influence on completion. In this case, changes to the layout may have impeded the completion rate for ASA Physical Status.

Anesthesia↗

PubMedDate not supplied

Influencing physician performance.

For physicians to change their behavior, they must internalize the need for change. One way to do this is to get the physicians to agree to the improvement. In this study, surgeons were asked to agree that documentation is important. When surgeons who agreed that documentation is important were compared with those who did not express agreement, those who agreed were more likely to provide the required clinical documentation. Furthermore, they showed improvement in their percentage of cases with the required documentation when compared to themselves over time. Simple strategies such as asking for a private commitment to change can enhance competency with documentation requirements.

Academic Medical Centers↗