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Keywords

Accuracy, Anesthesia information management system and nursing documentation, Completeness, Information management system

 

Authors

  1. WILBANKS, BRYAN A. DNP, CRNA

Abstract

An anesthesia information management system is a dynamic electronic documentation system that generates the legal records of patient care while the patient is receiving anesthesia. The generated documentation can be used to guide patient care, facilitate billing for services, and be used for clinical research. The purpose of this article was to synthesize the previous empirical and theoretical literature pertaining to the concept of accuracy in documentation in a wide range of disciplines in order to refine the concept and more effectively guide future research, clinical practice, and policy development in anesthesia informatics. The basic definition of accuracy is generally agreed upon, but the exact method of measuring accuracy is very different across disciplines. The concept of accuracy is defined in the published literature using the terms completeness, comprehensiveness, correctness, precision, legibility, readability, quantity of data, redundancy of data, clearness of data, concordance of data, and legitimacy. In nursing, accuracy can be defined as the presence of correct data that provide a complete, comprehensive, and precise representation of patient care. In anesthesia, accuracy is often defined in terms of correctness and completeness of data. Correctness, completeness, comprehensiveness, and precision are the primary constituents of accuracy with each discipline emphasizing different aspects.