Department of BioMechanical Engineering, Faculty of Mechanical Engineering, Delft University of Technology, Mekelweg 2, 2628 CD, Delft, The Netherlands.
World J Surg. 2013 Aug;37(8):1841-50. doi: 10.1007/s00268-013-2050-5.
Operative notes are the gold standard for detecting adverse events and near misses and form the basis for scientific research. In order to guarantee safe patient care, operative notes must be objective, complete, and accurate. This study explores the current routine of note writing for laparoscopic cholecystectomy (LC) and the differences between the notes of attendings and residents.
Attendings and residents were sent a DVD with footage of three LCs and were asked to "write" the corresponding notes and to complete a questionnaire. Dictation tapes were transcribed and items in the notes were analyzed for each procedure ("item described" or "item not described"). Fisher's exact tests were performed using SPSS 16.0 for Mac.
Thirteen sets of typewritten notes and 10 dictation tapes were returned. The results of the questionnaire showed that 16 of the 23 sets of notes were dictated. Eight participants found the current system for generating notes inadequate. 14 items (31 %) were included more often in the attendings' notes and 25 items (56 %) were included more often in the residents' notes. Overall, residents significantly more often described the location of the epigastric trocar (P = 0.018), the size of both working trocars (P = 0.019), the opening of the peritoneal envelope (P = 0.002), Critical View of Safety reached (P = 0.002), and the location for removing the gallbladder (P = 0.019). With the exception of "gallbladder perforation" (20 of 21 notes), complications were underreported.
In this study residents described more items than attendings. All notes lacked information concerning complications in the procedure, which makes the notes subjective and incomplete. A procedure-specific template or black-box-based operative notes based on established guidelines could improve the quality of the notes of both attendings and residents.
手术记录是发现不良事件和险兆事件的金标准，也是科学研究的基础。为了保证患者安全，手术记录必须客观、完整、准确。本研究旨在探讨腹腔镜胆囊切除术（LC）的手术记录常规，以及术者和住院医师手术记录的差异。
术者和住院医师观看了 3 台 LC 的录像，并被要求“书写”相应的手术记录并完成一份调查问卷。将口述录音转录为文字，分析每份手术记录中的项目（“项目描述”或“项目未描述”）。使用 SPSS 16.0 for Mac 进行 Fisher 精确检验。
共收到 13 份打印版手术记录和 10 份口述录音。问卷结果显示，23 份手术记录中有 16 份是口述记录的。8 名参与者认为当前的手术记录生成系统不完善。14 个项目（31%）在术者的手术记录中更常被记录，25 个项目（56%）在住院医师的手术记录中更常被记录。总体而言，住院医师更常描述上腹部穿刺套管的位置（P = 0.018）、两个工作套管的大小（P = 0.019）、腹膜外间隙的开口（P = 0.002）、达到安全关键视野（P = 0.002）和胆囊切除的位置（P = 0.019）。除了“胆囊穿孔”（21 份记录中的 20 份），并发症的记录较少。
在本研究中，住院医师描述的项目多于术者。所有记录都缺乏手术过程中并发症的信息，这使得记录具有主观性和不完整性。基于特定手术程序的模板或基于既定指南的黑盒式手术记录可以提高术者和住院医师手术记录的质量。
