Review of a documentation procedure
Conditions
Interventions
Group 1: All patients who received general anesthesia in urology/general surgery
Distribution by department
-250 records per time period and department
Analysis period
-Initial training through 6 mont
Sponsors
Universität Marburg Fachbereich Medizin
Eligibility
Sex/Gender
All
Age
18 Years to 80 Years
Inclusion criteria
Inclusion criteria: Inclusion criteria: • Age: 18 to 80 years • Elective surgeries in general surgery/urology or • Emergency procedures in general surgery/urology with marked urgency o N00 – Surgery begins immediately in life-threatening situations o N01 – Surgery begins within 1 hour of notification o N06 – Surgery begins within 6 hours of notification • General anesthesia administered
Exclusion criteria
Exclusion criteria: Exclusion criteria: • Documented frequent staff changes (= 3 anesthesiologists involved) during procedures and the resulting uncertainty regarding which individual is responsible for the documentation in terms of professional experience. o Exception: all anesthesiologists involved have the same level of training. • Documentation performed exclusively by a nurse • Planned regional anesthesia/analgesic sedation alone
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| Primary endpoint: • Change in the completeness of the documentation content, measured as a percentage of the total possible score, when comparing the study periods. | — |
Secondary
| Measure | Time frame |
|---|---|
| Secondary endpoints • Completeness of individual documentation entries relative to one another (measured as a percentage where documentation was required) o Manually added lines with conditional content (content expected based on another recorded event) compared to predefined lines • Completeness of documentation content relative to the duration of anesthesia • Specialty-specific completeness of documentation (general surgery vs. urology) • Completeness of documentation by urgency of the surgery • Differences in completeness based on the users’ professional experience | — |
Countries
Germany
Contacts
Public ContactBenedikt Schäfer
Klinikum Fulda
Outcome results
None listed