Queen Alexandra Hospital, Portsmouth, UK.
J Surg Educ. 2013 May-Jun;70(3):373-6. doi: 10.1016/j.jsurg.2012.12.003.
Accurate and legible record keeping is a crucial part of good medical practice. Surgical Hospital Audit of Record Keeping (SHARK) is a new audit and teaching tool for junior doctors. The author has designed the tool, based on the Royal College of Surgeons guidelines, to anonymously score the different surgical teams' medical records within a hospital. It takes into account regular record keeping during ward rounds, together with the operation note and admission clerking.
The SHARK audit tool assesses 45 individual areas within surgical records. Fifteen points are apportioned for an initial surgical clerking, 13 for a subsequent record entry, and 17 for the operation note to give an overall score out of 45. It was implemented at 2 hospitals and used to educate medical students.
The results were poor and improved with education at both sites. There was 80% total agreement with a κ coefficient for interobserver reliability of 0.6.
This study shows that the SHARK tool is simple to use, repeatable, and reliable in improving record keeping.
准确、清晰的记录保存是良好医疗实践的关键部分。《外科医院记录审核（SHARK）》是一种新的审计和教学工具，适用于初级医生。作者根据皇家外科学院的指南设计了该工具，旨在对医院内的不同外科团队的病历进行匿名评分。它考虑了在病房查房期间的常规记录保存，以及手术记录和入院记录。
SHARK 审核工具评估了外科记录中的 45 个单独区域。初始手术记录分配 15 分，随后的记录条目分配 13 分，手术记录分配 17 分，总分为 45 分。该工具在 2 家医院实施，并用于教育医学生。
在这两个地点，经过教育后，结果有所改善，但仍不理想。总体上有 80%的一致性，观察者间可靠性的κ系数为 0.6。
这项研究表明，SHARK 工具简单易用，可重复使用，并且在改善记录保存方面可靠。
