According to a retrospective study, less than 3% of electronic medical records (EMRs) for patients undergoing urgent/emergent intubations (UEIs) outside the operating room contained full documentation by anesthesia residents, Anesthesiology.com reported.
The retrospective study of 136 standardized electronic medical records (EMRs) documenting non-OR UEIs at Tufts Medical Center in Boston, between Jan. 1, 2016, and Feb. 28, 2017, found that only four of the notes (2.9%) included all 12 essential items.
Incomplete documentation could result in a mismatch between the resources necessary at peri-extubation and those that were present, said Andrea Tsai, MD, a critical care anesthesiologist at Tufts Medical Center. For example, “precautions may be taken when extubating a patient who is a known difficult airway in order to facilitate reintubation, should extubation fail. However, if there is no documentation of airway difficulty and extubation fails, the patient could experience morbidity during efforts to re-secure their airway.”