Table 2
Bibliography of the Articles Utilizing the Concept of Accuracy
Author/Year
Design/Purpose
Sample
Method
Theory
12,287 electronic
anesthesia records from
a 17 OR* hospital in
Jerusalem were
collected over a one
year time period.
The AIMS built-in query function
transferred endotracheal tube
size, laryngoscope blade size, and
intravenous access device
size/location from all anesthesia
records into an Access database.
Data concordance is
the proxy for
accuracy, defined as
the use of age
appropriate equipment
(i.e, appropriate size).
Anesthesia specific literature
Avidan &
Weisman (2012)
This study was a
retrospective chart
review to determine
data concordance
between specific
documentation data
and the patient's age.
Data completeness is
the presence of
mandatory data fields.
Benson et al. (2001)
This study was a
retrospective chart
review for
comparison of
manually entered and
automatically entered
vital signs in terms of
variability of data and
improbable results.
22,531 electronic
anesthesia records from
a hospital in Germany
were collected over a
two year time period.
Only the physiological
data (vital signs) were
analyzed.
The AIMS** database was
queried using SQL. Variability
was calculated for automatically
documented vital signs and for
manually entered vital signs.
Data validity is
defined as a plausible
result (i.e., physically
possible and highly
likely).
Data variability was
calculated using
estimation of variance
statistics.
Table 2- (Continued)
Author/Year
Design/Purpose
Sample
Method
Theory
Anesthesia specific literature (continued)
Bloomfield &
Feinglass (2008)
This is a review
article [editorial]
providing an
overview of the
reasons associated
with the slow
adoption of AIMS**
and the benefits of
implementing them.
The literature review
focused on potential
uses of AIMS with a
focus on advantages,
disadvantages, patient
safety, and error
reduction.
A very basic literature review
presenting some research studies,
but no critiquing. This article
presents information that supports
the significance of accuracy in
documentation.
Quality in AIMS
documentations
defined in terms of
preciseness; clear &
concise
documentation; and
accuracy.
Devitt et al. (1999)
This study was a onegroup, prospective,
single-blinded,
observational design
that was used for the
purpose of
determining if the
level of training and
years of anesthesia
experience have an
effect on the accuracy
of anesthesia
documentation.
A convenience sample
of 124 total participants
that included medical
students, anesthesia
residents, and
anesthesiologists from
an academic institution
were included in the
study. No time frame of
data collection was
given.
Participants were observed during
a simulated anesthesia case in a
controlled laboratory
environment. They managed the
care of a simulated patient that
experience 3 adverse events each.
The generated anesthesia record
was then compared to the
electronic simulator for
comparison of key vital signs.
Completeness is
defined as having data
present for every
physiological variable
for each adverse event.
Discrepancy, the
proxy for accuracy in
physiological
variables, is the
difference between
observed and recorded
values divided by the
actual value. [observed
– actual]/actual
Table 2- (Continued)
Author/Year
Design/Purpose
Sample
Method
Theory
Driscoll, Columbia,
This study was a
& Peterfreund (2007) retrospective chart
review to determine
sources of incomplete
data in electronic
anesthesia records.
All electronic anesthesia
records for a one month
period at a large
academic hospital in the
United States (N =
2838) were included in
the analysis.
The anesthesia records were
reviewed for the presence of
patient allergies, intravenous
access type, electrocardiogram
rhythm, ease of mask ventilation,
grade of laryngoscopic view, and
depth of endotracheal tube
placement.
Completeness is
defined as the
presence of predetermined mandatory
data fields (six in this
study).
Edsall et al. (1993)
3 nurse anesthetists
(volunteer convenience
sample) were observed
for a total of 10
anesthesia cases that
were performed
consecutively.
Two reviewers (identified as
authors of the manuscript)
reviewed the anesthesia records
and videotape. The video was
assessed for the amount of time
the nurse anesthetist spent on
documentation generation. The
documentation was reviewed for
completeness with a 46-item
questionnaire. Accuracy of
documentation was reflected by
quantity of data collected.
Accuracy is defined in
terms of the quantity
of physiological data
(vital signs) that can
be recorded.
Anesthesia specific literature (continued)
This study was a
prospective
observational design
using video recording
of simulated
anesthesia cases for
the purpose of
comparing manual
anesthesia
documentation with
an automated
anesthesia
information
management system.
Completeness is
determined by the
presence of predefined mandatory
data fields
Table 2- (Continued)
Author/Year
Design/Purpose
Sample
Method
Theory
Anesthesia specific literature (continued)
Thrush (1992)
A prospective,
blinded, descriptive
study of one group
was conducted for the
purpose of
determining the
difference in accuracy
between paper-based
and electronic
anesthesia
documentation.
A convenience sample
of 13 anesthesiologists
documented using a
paper based anesthesia
record and an electronic
record system during the
course of one anesthetic
each.
The paper based anesthesia
record and the electronic
anesthesia record both had the
frequencies of deviations from
pre-defined values (normal
physiological ranges) in systolic
blood pressure, diastolic blood
pressure, heart rate, end-tidal
carbon dioxide, and specific
hemoglobin calculated. The
corresponding electronic &
manual records were compared
using Fisher's exact test.
Accuracy differences
between manual &
electronic anesthesia
records are quantified
by computing the
frequencies of
deviations from predefined limits. This
overcomes the
obstacle of trying to
compare two graphical
displays of vital signs
that use different time
intervals.
Wilbanks, Moss, &
Berner (2012)
A prospective,
descriptive
observational study
conducted for the
purpose of identifying
sources of inaccuracy
in incompleteness in a
newly implemented
information
management system.
A convenience sample
of 20 anesthesia cases
involving nurse
anesthetists.
Nurse anesthetists were observed
during the entire intraoperative
period of anesthesia care. Study
participants were given a
questionnaire to assess perceived
accuracy and satisfaction with the
anesthesia information
management system.
Accuracy is defined in
terms of correctness of
data; using percentagreement statistics as
a proxy.
Completeness is
determined using a
pre-defined list of
required charting
elements.
Table 2- (Continued)
Author/Year
Design/Purpose
Sample
Method
Theory
All paper-based
anesthesia records (N =
890) from a three year
time period were
reviewed at a hospital in
Thailand.
A 44-item checklist was used by
anesthesiologists scoring each
category on a scale using the
groupings “good”, “fair”, “poor”,
or “no data”. Each anesthesia
record (N = 890) was manually
reviewed using this checklist.
Data analysis was performed by
calculating frequencies and using
Chi-square between the complete
and incomplete groups.
Completeness is
determined by the
presence of predetermined mandatory
data elements. The
authors evaluated
accuracy in terms of
the degree of
completeness.
Anesthesia specific literature (continued)
Yunuswangsa &
Nimmaanrat (2008)
A retrospective chart
review was conducted
to quantify anesthesia
record completeness.
Table 2- (Continued)
Author/Year
Design/Purpose
Sample
This study is a one
group descriptive
study for the purpose
of testing the
performance of a
specific logistic
regression model on
evaluating the
accuracy of machines
that determine
genomic mapping.
(The disciplines of
electrical engineering
and genetic
bioinformatics are
represented in this
study.)
A training data set was
used to test the model (a
known genomic map).
Method
Theory
Non-nursing literature
Ruffalo et al. (2012)
A known data set was read by
genomic mapper and the logistic
regression model was used to
measure the accuracy of the
mapper. Since a known genetic
set was used the results of the
genomic mapping could be
compared to the already known
values.
Accuracy is defined as
a data set that very
closely represents
actual values. The
determination of
accuracy requires
comparison of
recorded data with
previously known
values.
Precision is the
primary aspect of
accuracy and is
defined as a measured
data set that correctly
represents "actual"
values.
Table 2- (Continued)
Author/Year
Design/Purpose
Sample
Method
Theory
The database being
evaluated in the study
was created using a
well-established
software program used
for mathematical
computations in optical
science.
The generated database were
created using linear algebra and
advanced calculus. The
databases represent the scattering
patterns of wave particles when
they hit spheroid particles. The
practical applications involve
remote sensing in the atmosphere
of earth (i.e., studying weather
and climate changes).
Accuracy is the degree
of correctly detecting
(measuring)
phenomenon. The
gold standard for
determining the
accuracy of a
measuring device is by
measuring an already
known phenomenon
and comparing the
outcome to the already
known value. In this
article the "known"
values are represented
by a database.
Non-nursing literature (continued)
Schmidt et al. (2009)
This article is a case
study for the purposes
of presenting a
benchmark database
for calculating
electromagnetic and
light scattering
properties of
spheroidal particles
(i.e., dust size matter).
This would allow
determination of
accuracy in
measurements. (This
article represents the
discipline of
meteorology.)
Table 2- (Continued)
Author/Year
Design/Purpose
Sample
Method
Theory
A reviewer (who was not clearly
identified) evaluated each death
certificate for all legally required
data elements and then evaluated
accuracy by comparing the data
in the death certificate to
available medical records.
Accuracy is correct
data fields that meet
pre-defined
requirements;
determined by data
concordance with
other records
containing the same
types of data. Having
correct data is not
enough, the data must
reflect meeting legal
requirements.
Non-nursing literature (continued)
Sellinger, Ellis, &
Harrington (2007)
This study is a crosssectional,
retrospective chart
review for the
purpose of
determining the
accuracy of death
certificates and
verifying all legally
required elements are
present. (This article
represents the
disciplines of
criminal justice and
medicine).
Every available death
certificate (N = 140)
from a single hospital
for a 4-month period,
starting in February
2004, was evaluated.
Completeness is
determined by the
presence of mandatory
data fields.
Table 2- (Continued)
Author/Year
Design/Purpose
Sample
Method
Theory
Callen, Alderton, &
McIntosh (2008)
This study is a
retrospective chart
review to determine
accuracy in discharge
summaries by
comparing discharge
medications with the
inpatient medication
record.
245 inpatient discharge
summaries (62%
electronic and 38%
handwritten) were
collected over a three
month period in 2005 at
an Australian hospital.
Discharge summaries where
analyzed in regards to discharge
medications by compiling a list of
all medications the patient was
prescribed and then directly
verifying the medications with
the patient's inpatient medication
administration record.
Discrepancy is a
difference between
observed and recorded
data (proxy for
accuracy and
completeness).
Callen & McIntosh
(2010)
This study was a
retrospective chart
review to determine
accuracy in patient
medication lists
created by health care
providers.
Discharge medication
lists (966 handwritten
and 842 electronically
generated) where
collected over a twoyear period in an
Australian 78-bed
hospital.
Patient's self-reported medication
lists (documented by nurses)
within the patient charts where
analyzed for drug details (drug
name, dosage, and schedule of
administration) and then
confirmed directly with the
patient for accuracy.
Correctness is the
presence of data that
reflects actual events
(confirmed by going
directly to the source
of the data).
Nursing literature
Completeness is a
component of
correctness and is
represented by the
frequency of missing
events.
Table 2- (Continued)
Author/Year
Design/Purpose
Sample
Method
Theory
413 inpatient records
from the same year
(2002) where included
in the study. The setting
was a Swedish hospital
that had surgical,
orthopedic, and medical
patients.
Two data collections instruments
(a pressure ulcer data collection
tool and comprehensiveness in
nursing documentation tool) were
used to collect data from patient
records. Two auditors
(undergraduate nursing students)
scored each record and then interrater reliability was calculated.
The same three nursing students
took turns performing the audit.
The results were compared with
physical exams by researchers
that were performed on the same
patients from a previous study.
Completeness is
defined with a 5-point
Likert scale that
measures
comprehensiveness of
nursing
documentation.
Nursing literature (continued)
Gunningberg &
Ehrenberg (2004)
This study was a
retrospective chart
review to determine
the accuracy of
nursing
documentation of
pressure ulcers.
Table 2- (Continued)
Author/Year
Design/Purpose
Sample
Method
Theory
10 hospitals in the
Netherlands (out of a
total of 94) were
randomly selected to
participate. A
convenience sample of
341 patient records was
obtained from these
hospitals. Data
collection occurred
between 2007 and 2008.
Two reviewers at a time, who
each had 20-hours of training on
the use of the D-catch instrument,
evaluated each patient record.
This resulted in total scores for
accuracy (evaluating the
categories of record structure,
admission data, nursing
diagnosis, nursing interventions,
outcome evaluations, and
legibility). Inter-rater reliability
was calculated to determine
agreement in evaluation.
Exploratory factor analysis with
principal components analysis
was conducted to evaluate the
results.
Accuracy is evaluated
using quantitative and
qualitative
components. The
quantity of data is an
aspect of accuracy
(i.e., if more data was
collected then the
record was more
accurate).
Nursing literature (continued)
Paans et al. (2010)
This study was a
cross-sectional
retrospective chart
review for the
purpose of describing
the accuracy in
nursing
documentation at a
specific hospital.
Completeness is
combined and
measured with
accuracy; and is
represented partially
by the quantity of data.
Table 2- (Continued)
Author/Year
Design/Purpose
Sample
Method
Theory
38 articles published
between 2001 and 2011
were identified for
inclusion in the review.
The keywords 'record keeping',
'documentation', 'documenting',
'records', 'paperwork', and 'care
plans' were used to identify
articles in Ovid, CINAHL,
Internurse, Eduserve, Intute, and
Google Scholar. A summary of
key concepts in the literature was
presented.
Accuracy is viewed in
terms of truthfully
representing patient
care by providing a
comprehensive
presentation of the
patient's experiences
using clear
terminology.
Nursing literature (continued)
Prideau (2011)
This manuscript
presented a basic
literature review on
nursing
documentation for the
purpose of defining
quality
documentation and
factors associated
with decreasing the
quality of
documentation.
Completeness is
defined as
comprehensive
documentation that
covers all aspects of
the nursing process.
Table 2- (Continued)
Author/Year
Design/Purpose
Sample
Method
Theory
Two hospitals (one
using electronic
documentation and one
using paper-based
documentation) were
used to collect data over
four consecutive days.
A total of 1312 records
were included for
analysis.
Two reviewers (trained coders)
analyzed the chart for
completeness of patient history,
physical examination, and
documentation that guides
medical decision making
(laboratory values, radiology
reports, vital signs, etc.). Interrater reliability was calculated to
determine agreement on the
evaluation. Completeness and
discrepancy rates were then
calculated.
Completeness is
defined as the
presence of predetermined mandatory
data elements.
Nursing literature (continued)
Silfen (2006)
This study was a
cross-sectional,
retrospective chart
review for the
purpose of comparing
the accuracy of
procedural coding
between a paperbased and electronic
documentation
system.
Discrepancy is the
difference in coding
between what was
actually coded and
what an "expert"
determines should
have been coded.
Accuracy is defined as
concordance between
discrepancy rates
between different
types of
documentation.
Table 2- (Continued)
Author/Year
Design/Purpose
Sample
Method
Theory
Nursing literature (continued)
Stengal et al. (2004)
Tse & You (2011)
This study was a
randomized
controlled trial
conducted for the
purpose of
determining if use of
a portable
documentation
system could improve
documentation
quality.
In 2001, 80 orthopedic
surgical patients were
consecutively
randomized to either
electronic or paperbased documentation.
This pilot study was a
retrospective chart
review conducted for
the purpose of
determining the
degree of accuracy in
electronic
documentation at a
primary care
physician’s office.
33 patients ranging from
infants to elderly
individuals, exact ages
not stated, were
recruited at an
Australian general
physician practice
setting.
Two "expert" evaluators
(orthopedic physicians) reviewed
patient records and determined if
all possible diagnosis were
documented with no redundancy;
based on physical assessments
and laboratory values in the
record. Completeness rates were
determined based on the
physician’s evaluations of the
possible and actual diagnosis
present.
Completeness is the
inclusion of all
possible diagnosis
based on documented
patient assessment.
The researcher confirmed
demographics, health history, and
current medications in the
patient's record directly with the
patient. Frequencies of
discrepancies were recorded.
Accuracy is defined in
terms of data
reflecting reality and is
determined by direct
confirmation with the
patient.
Quality in
documentation is
represented by
completeness of data
without redundancy.
Completeness is not a
separate concept but is
incorporated into the
determination of
accuracy.
Table 2- (Continued)
Author/Year
Design/Purpose
Sample
Method
Theory
77 articles published
from 2000 to 2010 were
identified in peerreviewed publications
written in English.
The keywords 'quality',
'evaluation', 'audit', 'nursing
records', and 'nursing
documentation' were used to
search CINAHL, the Cochrane
Library, Health Reference Center,
ProQuest, InterScience, Medline,
and Nursing Resource Centre
databases. Articles dealing with
auditing nursing documentation
were included in the final
analysis. All data was abstracted
into Endnote for processing and
synthesis.
Completeness is
evaluated using audit
instruments specific to
the type of
documentation being
evaluated (mandatory
data fields).
Nursing literature (continued)
Wang, Hailey, & Yu
(2011)
This manuscript is a
mixed-method
systematic literature
review for the
purposes of
summarizing how the
quality of nursing
documentation is
evaluated (i.e.,
audited).
Accuracy is defined as
concordance between
patient assessment and
documentation.
Determination of
accuracy requires
going directly to the
source of the data for
confirmation.
Note. This is a summary of all of the articles included in the integrative literature review. None of the studies identified a specific
theoretical framework. The theoretical and conceptual definitions of the concepts related to accuracy are included.
*operating room (OR)
**anesthesia information management system (AIMS)