Influence of form structure on the anesthesia preoperative evaluation

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.