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A-1363
2003
Structured Response Improves Data Capture in Pre-Anesthesia Evaluation Forms
Alan P. Marco, M.D., M.M.M., Debra D. Buchman, Ph.D., R.N.
Department of Anesthesiology, Medical College of Ohio, Toledo, Ohio.
Background:

Two basic strategies are currently utilized for completion of data forms. Free text, where any text can be used to complete the answer, has the purported advantage of the richness of natural language and delivery of more information. However, the variability of responses makes the use of this information in databases and electronic storage as well as its analysis difficult. The use of structured responses, where the choices are limited, facilitates database utilization, but may lose some of the information found in free text. This study was undertaken to compare the capture of clinical information on the pre-anesthetic evaluation form, comparing a free text form to a structured response form.

Methods:

This prospective interventional study was approved by the Institutional Review Board. The Department of Anesthesiology at the Medical College of Ohio changed the format of the pre-anesthesia evaluation form from a free text version to one utilizing structured response for clinical history. The Health Information Management Department generated a random sample of charts of patients presenting for surgery in the time periods before and after the introduction of the new form from a list of patients with a principle discharge diagnosis in 18 higher complexity Diagnosis Related Groups (DRGs). The DRGs included major chest procedures (075), peripheral vascular disorders (130), major small and large bowel procedures (148), major joint and limb procedures (209), and kidney transplants (302). One of the two investigators reviewed these charts for the presence or absence of information on 18 clinical history items pertinent to the pre-anesthetic evaluation. The post-intervention group of 70 charts was compared to a sample of 63 historical controls using Fisher’s exact test.

Results:

For all 18 clinical history items, the structured forms were more likely to contain information regarding the presence or absence of the condition. Examples are shown in Table 1.Even when other portions of the medical record contained the information prior to the pre-anesthetic assessment, the use of the structured response form led to significantly improved data capture by physicians (Table 2).Conclusions:

The use of a structured response form for pre-anesthetic evaluation was associated with significantly improved data collection.

Anesthesiology 2003; 99: A1363
Table 1. Comparison of Random Samples of Free Text and Structured Response Forms for Preanesthetic Clinical History Information
Clinical ConditionPercent of Pre-Anesthetic Forms with Information
Free Text Forms (N = 63)Structured Response Forms (N = 70)*
Cardiac HistoryMyocardial Infarction1194
Hypertension5297
Arrhythmia8.990
Angina2591
Pulmonary HistorySmoking6397
Asthma1797
Recent URI3.294
Anesthetic HistoryDifficult Intubation1.697
Malignant Hyperthermia1.697
Post Operative Nausea and Vomiting1.699
* For all tests: p < 0.001, Fisher’s exact test
Table 2. Comparison of Random Samples of Free Text and Structured Response Forms for Data Completion When Information is Available Before the Pre-Anesthesia Evaluation
Clinical ConditionPercent of Forms with Information
Free Text FormsStructured Response Forms*
Cardiac HistoryMyocardial infarction2293
Hypertension5197
Arrhythmia1392
Angina3294
Pulmonary HistorySmoking72100
Asthma3887
Recent URI10100
*For all tests: p < 0.001, Fisher’s exact test