Nzenza Tatenda C, Manning Todd, Ngweso Simeon, Perera Marlon, Sengupta Shomik, Bolton Damien, Lawrentschuk Nathan
Department of Surgery, Austin Hospital, The University of Melbourne, Melbourne, Victoria, Australia.
Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.
ANZ J Surg. 2019 Mar;89(3):176-179. doi: 10.1111/ans.14239. Epub 2017 Nov 17.
Surgical operation notes are crucial for medical record keeping and information flow in continued patient care. In addition to inherent medical implications, the quality of operative notes also has important economic and medico-legal ramifications. Further, well-documented records can also be useful for audit purposes and propagation of research, facilitating the improvement of delivery of care to patients. We aimed to assess the quality of surgical operation notes written by junior doctors and trainees against a set standard, to ascertain whether these standards were met.
We undertook an audit of Urology and General Surgery operation notes handwritten by junior doctors and surgical trainees in a tertiary teaching hospital over a month period both in 2014 and 2015. Individual operative notes were assessed for quality based on parameters described by the Royal College of Surgeons of England guidelines.
Based on the Royal College of Surgeons of England guidelines, a significant proportion of analysed surgical operative notes were incomplete, with information pertaining to the time of surgery, name of anaesthetist and deep vein thrombosis prophylaxis in particular being recorded less than 50% of the time (22.42, 36.36 and 43.03%, respectively).Overall, 80% compliance was achieved in 14/20 standards and 100% compliance was attained in only one standard.
The quality of surgical operation notes written by junior doctors and trainees demonstrated significant deficiencies when compared against a set standard. There is a clear need to educate junior medical staff and to provide systems and ongoing education to improve quality. This would involve leadership from senior staff, ongoing audit and the development of systems that are part of the normal workflow to improve quality and compliance.
手术记录对于病历保存以及患者后续治疗中的信息流通至关重要。除了固有的医学意义外，手术记录的质量还具有重要的经济和医疗法律影响。此外，记录完备的病历对于审计目的和研究传播也很有用，有助于改善对患者的护理服务。我们旨在根据既定标准评估初级医生和实习生书写的手术记录的质量，以确定这些标准是否得到满足。
我们对一家三级教学医院的泌尿外科和普通外科手术记录进行了审计，这些记录由初级医生和外科实习生在2014年和2015年的一个月时间内手写而成。根据英国皇家外科医学院指南所描述的参数，对每份手术记录的质量进行评估。
根据英国皇家外科医学院指南，很大一部分分析的手术记录不完整，特别是关于手术时间、麻醉师姓名和深静脉血栓预防的信息记录不到50%的时间（分别为22.42%、36.36%和43.03%）。总体而言，20项标准中有14项达到了80%的合规率，只有一项标准达到了100%的合规率。
与既定标准相比，初级医生和实习生书写的手术记录质量存在明显缺陷。显然有必要对初级医务人员进行教育，并提供系统和持续教育以提高质量。这将需要高级工作人员的领导、持续审计以及开发作为正常工作流程一部分的系统，以提高质量和合规性。
