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Influence of form structure on the anesthesia preoperative evaluation
Original Contributions Influence of Form Structure on the Anesthesia Preoperative Evaluation Alan P. Marco, MD,* Debra Buchman, RN, PhD,† Colleen Lancz, MD‡ Department of Anesthesiology, Medical College of Ohio, Toledo, OH; and School of Nursing, Medical College of Ohio, Toledo, OH
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. Interventions: 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. © 2003 by Elsevier Inc. Keywords: Preoperative evaluation; data forms; medical records; recordkeeping. *Associate Professor of Anesthesiology †Associate Professor of Nursing
Introduction
‡Assistant Professor of Anesthesiology
Documentation of care is an important part of medical treatment. In the present health care environment, increased emphasis on documentation is a result of the requirements of third-party payers, both private and governmental. Many factors affect the quality of documentation, such as ease of use of forms, provider interest, and the availability of information. Good documentation may help improve patient care by easing the transfer of information from one provider to another. A review of reports from the Australian Incident Monitoring Study suggested that improvements in information exchange would help prevent at least some of the incidents reported.1 Other researchers have found that
Address correspondence to Dr. Marco at the Department of Anesthesiology, Medical College of Ohio, 3000 Arlington Avenue, Toledo, OH 43614-2598. E-mail: amarco@mco. edu Received for publication February 26, 2002; revised manuscript accepted for publication December 2, 2002. Journal of Clinical Anesthesia 15:411⫺417, 2003 © 2003 Elsevier Inc. All rights reserved. 360 Park Avenue, South, New York, NY 10010
0952-8180/03/$–see front matter doi:10.1016/S0952-8180(03)00079-5
Original Contributions
Table 1. Frequencies of the Components of the Preoperative Evaluation Form Nonstructured Form Form Component Addressograph Proposed Surgery Current Medications Medication Doses/Frequency Allergies ASA Physical Status Anesthesia Plan Attending Note NPO Status
Present (%)
Absent (%)
94 (84) 105 (94) 108 (96) 6 (5) 111 (99) 109 (97) 96 (86) 43 (38) 60 (54)
18 (16) 7 (6) 4 (4) 94 (84) 1 (1) 3 (3) 16 (13) 69 (62) 52 (46)
Structured Form
Not Applicable (%)
12 (11)
1 (1)
Present (%)
Absent (%)
98 (93) 77 (73) 98 (94) 19 (18) 102 (97) 78 (74) 90 (86) 83 (79) 49 (47)
7 (7) 28 (27) 6 (6) 66 (64) 3 (3) 27 (26) 15 (14) 22 (21) 56 (53)
Not Applicable (%)
19 (18)
Note. () ⫽ Percent of total. If the patient was taking no medications, then doses was considered “not applicable.”
essential elements of the preanesthesia assessment are frequently missing from notes.2 Several studies have examined the influence of the electronic record on accuracy, vigilance, or workload of charting in the intraoperative period.3–5 However, little work has been done on the influence of the design of the preoperative evaluation tool on necessary data collection. In this study, we examined the configuration of a standardized preoperative anesthesia form to determine its effect on documentation of representative elements of the preanesthesia assessment.
Materials and Methods The Medical College of Ohio’s Institutional Review Board approved this study. Before 1999, a basic form for anesthesiology preoperative evaluation was used (Figure 1). In April 1999, a new anesthesiology preoperative evaluation form was developed (Figure 2). While the new form included prompts for many medical history items, it also had prompts for specific elements needed for billing (Addressograph), compliance (Anesthesia Plan, Attending Note), and general assessment (Proposed Surgery, Current Medication, Medication Doses, Allergies, ASA Physical Status, NPO Status). In August 1999, this revised form was reprinted using new software for consistency in appearance with other hospital forms that were being developed; however, the data elements and overall layout were similar. To evaluate the impact on data collection from the change in format, charts from the time period before and after the introduction of the new form style were audited. Because of the continued circulation of the old version of the form, a total of 112 charts with the old form and 105 charts with the new form were actually reviewed. Charts were reviewed by staff of the Quality Management Department of the hospital or by one of the authors (A.P.M.). Pertinent elements included: Addressograph Stamp, Proposed Surgery, Current Medications, Medication Doses/Frequency, Allergies (must agree with any other notation in chart), ASA Physical Status, Anesthesia Plan, Attending Note, and NPO Status. Percentages of charts with the required indicators were determined and compared between groups by testing hypotheses 412
J. Clin. Anesth., vol. 15, September 2003
about the difference in the proportions in the two independent samples of medical records containing either the nonstructured or the structured preoperative evaluation form. These proportions were tested using a Bonferroni correction for each of the analyses to hold the total Type I error rate at 0.05.
Results Comparisons of the frequencies for completed documentation on the nonstructured versus the structured form are presented in Table 1. The most notable differences are in the Proposed Surgery, ASA Physical Status, and Attending Note. The statistical tests of the differences in proportions of completed documentation between the nonstructured and the structured form are presented in Table 2 along with the confidence intervals for each test. The decreases in the proportions of completed documentation on the structured form for Proposed Surgery and ASA Physical Status were statistically significant. The proportion of Table 2. Tests of the Differences in Proportions of Completed Documentation Between the Non-structured and Structured Preoperative Evaluation Forms
Form Component Addressograph Proposed Surgery Current Medications Medication Doses/ Frequency Allergies ASA Physical Status Anesthesia Plan Attending Note NPO Status
Test Statistic (z)
SE of Difference (sp1–p2)
95% Confidence Interval for the Difference in Proportions
⫺2.17 4.09* 0.77 ⫺2.96*
0.04 0.05 0.03 0.04
⫺0.20, 0.02 0.08, 0.20 ⫺0.05, 0.02 ⫺0.24, ⫺0.13
1.08 4.91* 0.00 ⫺6.07* 1.02
0.02 0.05 0.00 0.07 0.07
⫺0.03, 0.02 0.11, 0.23 ⫺0.12, 0.00 ⫺0.58, ⫺0.41 ⫺0.10, 0.07
*Significant differences using a Bonferroni correction. SE ⫽ standard error; NPO ⫽ fasting.
Figure 1. Original anesthesiology preoperative evaluation form. This form is based on free-text and provides only a general guide for data elements required for the preoperative evaluation. It is brief and a single side of a single page. J. Clin. Anesth., vol. 15, September 2003
413
Figure 2. Revised anesthesiology preoperative evaluation form. a. Side 1. This form uses structured responses for clinical data and also provides cues for free-text entry. 414
J. Clin. Anesth., vol. 15, September 2003
Figure 2 Revised anesthesiology preoperative evaluation form. b. Side 2. J. Clin. Anesth., vol. 15, September 2003
415
Original Contributions
completed Attending Notes was significantly higher with the structured form. The increase in the proportion of completed documentation of Medication Doses was statistically significant, but it remained relatively low on the structured form. The other indicators were not significantly different between the two groups.
Discussion Several factors may account for the difference between the two groups. There may have been differences in the attitudes of the department as to the significance of the documentation. However, because the audit periods were under 1 year apart, it is unlikely that significant differences in staff attitudes could account for the differences between groups. Similarly, these administrative components were required elements of the preoperative evaluation during the entire time period, so changes in requirements were unlikely to affect form completion. Increased emphasis by the institution may have accounted for some of the difference. Because efforts to educate the physician staff on the need for complete documentation were made by the institution, faculty may have been more careful about documentation, including Attending Note. During the audit periods of the new form, an Attending Note (not merely a signature) was more likely to be present (79% vs. 36%). To meet medical direction rules, an actual note by the attending physician (not merely co-signing a resident’s or nonphysician provider’s note) is needed. Thus, the layout and structure of the form may help in meeting compliance goals. Finally, the new form may have been easier to use, and because it prompted for information, it may have been more likely to have been filled out completely. However, even a well designed form will not be completed if the physician does not think the data element is important. This may be the explanation for why the Medication Doses section was typically not filled out. Although it is important for anesthesiologists to know which medications their patient takes, they typically are not concerned with the doses, especially in outpatients who resume their regular routines quickly, because the anesthesiologists usually will not be writing admission orders. This situation also raises the question as to whether or not these data should be required in the evaluation if the practitioners do not find them useful. However, two other findings suggest that the layout of the new form did not completely encourage its completion. Neither the Proposed Surgery nor the ASA Physical Status was improved on the new form. Actually, they were both significantly worse on the new form than the old. One likely explanation is that the design of the new form actually inhibited its proper completion. Others have noted that the design of a form is important in its ease of use, but there exist only limited data in the medical literature to back up this claim.6 In the older form, the Proposed Surgery was surrounded by “white space,” whereas in the new form it was a small line in a crowded section. This placement may have contributed to its being overlooked. Similarly, on the old form, the ASA Physical Status appeared at the end of the one-page document 416
J. Clin. Anesth., vol. 15, September 2003
where it could be completed in a natural sequence at the end of the overall evaluation. In the new form, it was on the first page of a two-page form, primarily to allow machine reading of the data. However, if the natural flow is to assign an ASA physical status at the end of the evaluation, it is awkward to turn back to the previous page to check the box. Similarly, when the Attending Note is completed (which was more common on the new form) the fact that the ASA Physical Status section is on the previous page makes it harder for the attending physician to make sure that the section is completed. In the study institution, the ASA Physical Status is also recorded on the intraoperative record; this was not cross-checked against the preoperative evaluation in this study. With feedback from the department staff and faculty, we revised somewhat the new design form. The new revision placed the ASA Physical Status section at the end of the second page, above the Attending Signature, in an attempt to improve completion. To confirm that the placement of the ASA Physical Status documentation affected its completion rate, and with local institutional review board approval, we surveyed an additional 60 revised charts solely to document completion of the ASA Physical Status section. Of these new forms, 53 (88.3%) had the ASA Physical Status completed and 7 (11.7%) did not. This finding was significantly different from the previous version of the form (z ⫽ –2.14, SE of the difference ⫽ 0.0668). Others have noted the importance of a well-designed preoperative evaluation form.7 In this study, the authors evaluated 138 forms for the presence of places to record information, and they gave higher scores to such devices as check boxes that eased completion. However, they did not have information as to whether or not the forms were properly completed. In this study, we showed that although a form may be intended to document pertinent medical and other information, the physical layout of the form may impede its completion.
Conclusion The design of a form can have a significant impact on its usability. In an era when there is increased emphasis on documentation, the design of a data form can have an impact on regulatory compliance as well as patient safety through the improved communication of patient information. Therefore, it is essential to design forms that can aid the user in completion. Although this study focuses on paper forms, the same principle can be applied to electronic forms. However, with electronic forms, there is the added advantage of making some data points mandatory with prompts to complete.
References 1. Kluger MT, Tham EJ, Coleman NA, Runciman WB, Bullock MF: Inadequate preoperative evaluation and preparation: a review of 197 reports from the Australian Incident Monitoring Study. Anaesthesia 2000;55:1173–8.
Form structure and preoperative evaluation: Marco et al. 2. Simmonds M, Petterson J: Anaesthetists’ records of pre-operative assessment. Clin Perform Qual Health Care 2000;8:22–7. 3. Hollenberg JP, Pirraglia PA, Williams-Russo P, et al: Computerized data collection in the operating room during coronary artery bypass surgery: a comparison to the hand-written anesthesia record. J Cardiothorac Vasc Anesth 1997;11:545–51. 4. Weinger MB, Herndon OW, Gaba DM: The effect of electronic record keeping and transesophageal echocardiography on task distribution, workload, and vigilance during cardiac anesthesia.
Anesthesiology 1998;87:144 –55. 5. Loeb RG: Manual record keeping is not necessary for anesthesia vigilance. J Clin Monit 1995;11:9 –13. 6. Knatterud GL, Forman SA, Canner PL: Design of data forms. Controlled Clin Trials 1983;4:429 –40. 7. Takata MN, Benumof JL, Mazzei WJ: The preoperative evaluation form: assessment of quality from one hundred thirty-eight institutions and recommendations for a high-quality form. J Clin Anesth 2001;13:345–52.
J. Clin. Anesth., vol. 15, September 2003
417
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. Interventions: 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. © 2003 by Elsevier Inc. Keywords: Preoperative evaluation; data forms; medical records; recordkeeping. *Associate Professor of Anesthesiology †Associate Professor of Nursing
Introduction
‡Assistant Professor of Anesthesiology
Documentation of care is an important part of medical treatment. In the present health care environment, increased emphasis on documentation is a result of the requirements of third-party payers, both private and governmental. Many factors affect the quality of documentation, such as ease of use of forms, provider interest, and the availability of information. Good documentation may help improve patient care by easing the transfer of information from one provider to another. A review of reports from the Australian Incident Monitoring Study suggested that improvements in information exchange would help prevent at least some of the incidents reported.1 Other researchers have found that
Address correspondence to Dr. Marco at the Department of Anesthesiology, Medical College of Ohio, 3000 Arlington Avenue, Toledo, OH 43614-2598. E-mail: amarco@mco. edu Received for publication February 26, 2002; revised manuscript accepted for publication December 2, 2002. Journal of Clinical Anesthesia 15:411⫺417, 2003 © 2003 Elsevier Inc. All rights reserved. 360 Park Avenue, South, New York, NY 10010
0952-8180/03/$–see front matter doi:10.1016/S0952-8180(03)00079-5
Original Contributions
Table 1. Frequencies of the Components of the Preoperative Evaluation Form Nonstructured Form Form Component Addressograph Proposed Surgery Current Medications Medication Doses/Frequency Allergies ASA Physical Status Anesthesia Plan Attending Note NPO Status
Present (%)
Absent (%)
94 (84) 105 (94) 108 (96) 6 (5) 111 (99) 109 (97) 96 (86) 43 (38) 60 (54)
18 (16) 7 (6) 4 (4) 94 (84) 1 (1) 3 (3) 16 (13) 69 (62) 52 (46)
Structured Form
Not Applicable (%)
12 (11)
1 (1)
Present (%)
Absent (%)
98 (93) 77 (73) 98 (94) 19 (18) 102 (97) 78 (74) 90 (86) 83 (79) 49 (47)
7 (7) 28 (27) 6 (6) 66 (64) 3 (3) 27 (26) 15 (14) 22 (21) 56 (53)
Not Applicable (%)
19 (18)
Note. () ⫽ Percent of total. If the patient was taking no medications, then doses was considered “not applicable.”
essential elements of the preanesthesia assessment are frequently missing from notes.2 Several studies have examined the influence of the electronic record on accuracy, vigilance, or workload of charting in the intraoperative period.3–5 However, little work has been done on the influence of the design of the preoperative evaluation tool on necessary data collection. In this study, we examined the configuration of a standardized preoperative anesthesia form to determine its effect on documentation of representative elements of the preanesthesia assessment.
Materials and Methods The Medical College of Ohio’s Institutional Review Board approved this study. Before 1999, a basic form for anesthesiology preoperative evaluation was used (Figure 1). In April 1999, a new anesthesiology preoperative evaluation form was developed (Figure 2). While the new form included prompts for many medical history items, it also had prompts for specific elements needed for billing (Addressograph), compliance (Anesthesia Plan, Attending Note), and general assessment (Proposed Surgery, Current Medication, Medication Doses, Allergies, ASA Physical Status, NPO Status). In August 1999, this revised form was reprinted using new software for consistency in appearance with other hospital forms that were being developed; however, the data elements and overall layout were similar. To evaluate the impact on data collection from the change in format, charts from the time period before and after the introduction of the new form style were audited. Because of the continued circulation of the old version of the form, a total of 112 charts with the old form and 105 charts with the new form were actually reviewed. Charts were reviewed by staff of the Quality Management Department of the hospital or by one of the authors (A.P.M.). Pertinent elements included: Addressograph Stamp, Proposed Surgery, Current Medications, Medication Doses/Frequency, Allergies (must agree with any other notation in chart), ASA Physical Status, Anesthesia Plan, Attending Note, and NPO Status. Percentages of charts with the required indicators were determined and compared between groups by testing hypotheses 412
J. Clin. Anesth., vol. 15, September 2003
about the difference in the proportions in the two independent samples of medical records containing either the nonstructured or the structured preoperative evaluation form. These proportions were tested using a Bonferroni correction for each of the analyses to hold the total Type I error rate at 0.05.
Results Comparisons of the frequencies for completed documentation on the nonstructured versus the structured form are presented in Table 1. The most notable differences are in the Proposed Surgery, ASA Physical Status, and Attending Note. The statistical tests of the differences in proportions of completed documentation between the nonstructured and the structured form are presented in Table 2 along with the confidence intervals for each test. The decreases in the proportions of completed documentation on the structured form for Proposed Surgery and ASA Physical Status were statistically significant. The proportion of Table 2. Tests of the Differences in Proportions of Completed Documentation Between the Non-structured and Structured Preoperative Evaluation Forms
Form Component Addressograph Proposed Surgery Current Medications Medication Doses/ Frequency Allergies ASA Physical Status Anesthesia Plan Attending Note NPO Status
Test Statistic (z)
SE of Difference (sp1–p2)
95% Confidence Interval for the Difference in Proportions
⫺2.17 4.09* 0.77 ⫺2.96*
0.04 0.05 0.03 0.04
⫺0.20, 0.02 0.08, 0.20 ⫺0.05, 0.02 ⫺0.24, ⫺0.13
1.08 4.91* 0.00 ⫺6.07* 1.02
0.02 0.05 0.00 0.07 0.07
⫺0.03, 0.02 0.11, 0.23 ⫺0.12, 0.00 ⫺0.58, ⫺0.41 ⫺0.10, 0.07
*Significant differences using a Bonferroni correction. SE ⫽ standard error; NPO ⫽ fasting.
Figure 1. Original anesthesiology preoperative evaluation form. This form is based on free-text and provides only a general guide for data elements required for the preoperative evaluation. It is brief and a single side of a single page. J. Clin. Anesth., vol. 15, September 2003
413
Figure 2. Revised anesthesiology preoperative evaluation form. a. Side 1. This form uses structured responses for clinical data and also provides cues for free-text entry. 414
J. Clin. Anesth., vol. 15, September 2003
Figure 2 Revised anesthesiology preoperative evaluation form. b. Side 2. J. Clin. Anesth., vol. 15, September 2003
415
Original Contributions
completed Attending Notes was significantly higher with the structured form. The increase in the proportion of completed documentation of Medication Doses was statistically significant, but it remained relatively low on the structured form. The other indicators were not significantly different between the two groups.
Discussion Several factors may account for the difference between the two groups. There may have been differences in the attitudes of the department as to the significance of the documentation. However, because the audit periods were under 1 year apart, it is unlikely that significant differences in staff attitudes could account for the differences between groups. Similarly, these administrative components were required elements of the preoperative evaluation during the entire time period, so changes in requirements were unlikely to affect form completion. Increased emphasis by the institution may have accounted for some of the difference. Because efforts to educate the physician staff on the need for complete documentation were made by the institution, faculty may have been more careful about documentation, including Attending Note. During the audit periods of the new form, an Attending Note (not merely a signature) was more likely to be present (79% vs. 36%). To meet medical direction rules, an actual note by the attending physician (not merely co-signing a resident’s or nonphysician provider’s note) is needed. Thus, the layout and structure of the form may help in meeting compliance goals. Finally, the new form may have been easier to use, and because it prompted for information, it may have been more likely to have been filled out completely. However, even a well designed form will not be completed if the physician does not think the data element is important. This may be the explanation for why the Medication Doses section was typically not filled out. Although it is important for anesthesiologists to know which medications their patient takes, they typically are not concerned with the doses, especially in outpatients who resume their regular routines quickly, because the anesthesiologists usually will not be writing admission orders. This situation also raises the question as to whether or not these data should be required in the evaluation if the practitioners do not find them useful. However, two other findings suggest that the layout of the new form did not completely encourage its completion. Neither the Proposed Surgery nor the ASA Physical Status was improved on the new form. Actually, they were both significantly worse on the new form than the old. One likely explanation is that the design of the new form actually inhibited its proper completion. Others have noted that the design of a form is important in its ease of use, but there exist only limited data in the medical literature to back up this claim.6 In the older form, the Proposed Surgery was surrounded by “white space,” whereas in the new form it was a small line in a crowded section. This placement may have contributed to its being overlooked. Similarly, on the old form, the ASA Physical Status appeared at the end of the one-page document 416
J. Clin. Anesth., vol. 15, September 2003
where it could be completed in a natural sequence at the end of the overall evaluation. In the new form, it was on the first page of a two-page form, primarily to allow machine reading of the data. However, if the natural flow is to assign an ASA physical status at the end of the evaluation, it is awkward to turn back to the previous page to check the box. Similarly, when the Attending Note is completed (which was more common on the new form) the fact that the ASA Physical Status section is on the previous page makes it harder for the attending physician to make sure that the section is completed. In the study institution, the ASA Physical Status is also recorded on the intraoperative record; this was not cross-checked against the preoperative evaluation in this study. With feedback from the department staff and faculty, we revised somewhat the new design form. The new revision placed the ASA Physical Status section at the end of the second page, above the Attending Signature, in an attempt to improve completion. To confirm that the placement of the ASA Physical Status documentation affected its completion rate, and with local institutional review board approval, we surveyed an additional 60 revised charts solely to document completion of the ASA Physical Status section. Of these new forms, 53 (88.3%) had the ASA Physical Status completed and 7 (11.7%) did not. This finding was significantly different from the previous version of the form (z ⫽ –2.14, SE of the difference ⫽ 0.0668). Others have noted the importance of a well-designed preoperative evaluation form.7 In this study, the authors evaluated 138 forms for the presence of places to record information, and they gave higher scores to such devices as check boxes that eased completion. However, they did not have information as to whether or not the forms were properly completed. In this study, we showed that although a form may be intended to document pertinent medical and other information, the physical layout of the form may impede its completion.
Conclusion The design of a form can have a significant impact on its usability. In an era when there is increased emphasis on documentation, the design of a data form can have an impact on regulatory compliance as well as patient safety through the improved communication of patient information. Therefore, it is essential to design forms that can aid the user in completion. Although this study focuses on paper forms, the same principle can be applied to electronic forms. However, with electronic forms, there is the added advantage of making some data points mandatory with prompts to complete.
References 1. Kluger MT, Tham EJ, Coleman NA, Runciman WB, Bullock MF: Inadequate preoperative evaluation and preparation: a review of 197 reports from the Australian Incident Monitoring Study. Anaesthesia 2000;55:1173–8.
Form structure and preoperative evaluation: Marco et al. 2. Simmonds M, Petterson J: Anaesthetists’ records of pre-operative assessment. Clin Perform Qual Health Care 2000;8:22–7. 3. Hollenberg JP, Pirraglia PA, Williams-Russo P, et al: Computerized data collection in the operating room during coronary artery bypass surgery: a comparison to the hand-written anesthesia record. J Cardiothorac Vasc Anesth 1997;11:545–51. 4. Weinger MB, Herndon OW, Gaba DM: The effect of electronic record keeping and transesophageal echocardiography on task distribution, workload, and vigilance during cardiac anesthesia.
Anesthesiology 1998;87:144 –55. 5. Loeb RG: Manual record keeping is not necessary for anesthesia vigilance. J Clin Monit 1995;11:9 –13. 6. Knatterud GL, Forman SA, Canner PL: Design of data forms. Controlled Clin Trials 1983;4:429 –40. 7. Takata MN, Benumof JL, Mazzei WJ: The preoperative evaluation form: assessment of quality from one hundred thirty-eight institutions and recommendations for a high-quality form. J Clin Anesth 2001;13:345–52.
J. Clin. Anesth., vol. 15, September 2003
417