Clinical trial NCT03076398: Development of Anaesthesia Electronic Medical Record
Official title: Feasibility Study and Prototype Computerised Program Development of Anaesthesia Electronic Medical Record
Study type: OBSERVATIONAL
Overall status: UNKNOWN
Conditions: Patient Compliance
Lead sponsor: Siriraj Hospital
Sponsor class: OTHER
First posted: 2017-03-10
Enrollment: 397
Sex: ALL
Minimum age (years): 18
Maximum age (years): 80
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Observational model: OTHER
Time perspective: PROSPECTIVE
Sampling method: NON_PROBABILITY_SAMPLE
Study population: All patients undergoing general or regional anaesthesia

Brief summary: Normally, anaesthesia personnel make a record patients' information during the surgical procedure. Pre and post-operatively, they visit patients to make sure that their customers are well informed regarding the whole process and satisfied with the service as well as any complications that might be existed.

The investigators would like to develop an anaesthesia electronic medical record at the point of care. The objectives are to record peri-operative patients' information in a real-time fashion, manage all administrative tasks as annual reports, and operate data as search engine for research and educational purpose.

Detailed description: Department of Anaesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University provides services to patients undergoing operative procedures in many fields; such as Traumatic surgery, Orthopaedics surgery, Eye surgery, Ear, Nose and Throat surgery, Plastics surgery, Cardio-thoracic surgery, Neurosurgery, General surgery, Urological surgery, Head and Neck surgery, Paediatric surgery, Obstetrics surgery, Gynaecological surgery, Electro-convulsive therapy, Radiological services, Endoscopic centre, Intensive Care Unit, Acute Pain service, Pain Clinic and Pre Anaesthesia Assessment Centre.

Normally, anaesthesia personnel make a patient information record during the surgical procedure. Pre and post-operatively, they visit patients to make sure that their customers are well informed regarding the whole process and satisfied with the service as well as any complications that might be existed.

The patient data, a crucial document for both medical and official terms, has been developed and improved continuously by the department. Daily, about 250 informations are transferred from paper-pencil to electronic, computerised format for statistical purpose and further reference. Still, the department has to face the data problem in many aspects.

1. Daily, an abundant of information needs to be transferred to computer by non-medical personnel. This results in time consuming, data loss and piles of document.
2. Unclear peri-operative handwriting of medical or technical terms, particularly on copied files results in untrustworthy and disgraceful of patients' evidence.
3. Scanned files results in difficulties of data retrieval for assignments in research, education, administrative policy and finance. Consequently, a hospital becomes an unfaithful and treacherous organisation.

The investigators would like to develop an anaesthesia electronic medical record at the point of care. The objectives are to record peri-operative patients' information in a real-time fashion, manage all administrative tasks as annual reports, and operate data as search engine for research and educational purpose.

Eligibility criteria: Inclusion Criteria:

* patients undergoing anaesthesia

Exclusion Criteria:

* N/A

Primary outcomes:
measure: Anaesthesia Electronic Medical Record
timeFrame: 2 year
Secondary outcomes:
Other outcomes:
Locations:
city: Bangkok Noi
country: Thailand
facility: Phongthara Vichitvejpaisal
state: Bangkok
Study officials:
affiliation: Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
name: Chairat Shayakul
role: STUDY_CHAIR
References: