Agreement on sedation-related events between a procedural sedation registry and computerized medical records.

OBJECTIVES Little is known about the accuracy of the medical record to document sedation-related events (SREs). Our hypotheses were that, when compared to a reference database (RD), a procedural sedation quality assurance registry (PSQAR) and medical records were accurate documentation of SREs. METHODS All cases in our PSQAR over 13 months were examined. Those with SREs were entered into the RD. We reviewed the computerized medical record (CMR; both physician documentation and nursing documentation) to determine the presence of procedural sedation notes and documentation of SRE. RESULTS A total of 203 sedation cases were entered into the PSQAR. The RD consisted of 74 SREs during 60 cases. The PSQAR included 61 (82%) of 74 events (95% confidence interval [CI], 72%-90%), whereas the CMR included 44 (60%) of 74 events (95% CI, 47%-71%). Physician documentation completely matched the RD in 12 (20%) 60 cases (95% CI, 11-32) and nursing documentation completely matched the RD in 24 (40%) of 60 cases (95% CI, 28-53). Physician and nursing documentation were complete and agreed with each other in only 4 (9%) of 60 cases (95% CI, 2-16; kappa = 0.13). CONCLUSION When compared to the RD, the accuracy of the PSQAR was very good. However, the accuracy of the CMR, including both nursing and physician documentation, was poor and there was poor agreement between them. This has implications for chart review-based research and quality improvement.

[1]  A. Sacchetti,et al.  The safety of single-physician procedural sedation in the emergency department , 2006, Emergency Medicine Journal.

[2]  M. Helfand,et al.  An analysis of Hospital Discharge Index as a trauma data base. , 1995, The Journal of trauma.

[3]  M. Greenberg,et al.  International variances in carbon dioxide absorbent colour indicators , 2007, Canadian journal of anaesthesia = Journal canadien d'anesthesie.

[4]  D. Hess.  Retrospective studies and chart reviews. , 2004, Respiratory care.

[5]  M. Mccarthy,et al.  Comparison of Maryland hospital discharge and trauma registry data. , 2005, The Journal of trauma.

[6]  M. Mccarthy,et al.  Validity of administrative data for characterizing traumatic brain injury-related hospitalizations , 2005, Brain injury.

[7]  S. Normand,et al.  Comparison of Clinical and Administrative Data Sources for Hospital Coronary Artery Bypass Graft Surgery Report Cards , 2007, Circulation.

[8]  Richard Platt,et al.  Administrative Databases Provide Inaccurate Data for Surveillance of Long-Term Central Venous Catheter-Associated Infections , 2003, Infection Control & Hospital Epidemiology.

[9]  Eric Silfen,et al.  Documentation and coding of ED patient encounters: an evaluation of the accuracy of an electronic medical record. , 2006, The American journal of emergency medicine.

[10]  T. Ryan.  To understand cardiac surgical report cards: look both ways. , 2007, Circulation.

[11]  James Strickland,et al.  Procedural sedation in the community emergency department: initial results of the ProSCED registry. , 2007, Academic emergency medicine : official journal of the Society for Academic Emergency Medicine.

[12]  F. Chung,et al.  Factors affecting recovery and discharge following ambulatory surgery , 2006, Canadian journal of anaesthesia = Journal canadien d'anesthesie.