Howard Matthew, Parwaiz Hammad, Cassels Emily, Smith Natalie, Howard Lucy
Core Surgical Trainee, Department of Surgery, Royal United Hospital Bath NHS Trust, Bath BA1 3NG.
Core Surgical Trainee, Department of Surgery, Royal United Hospital Bath NHS Trust, Bath.
Br J Hosp Med (Lond). 2018 Apr 2;79(4):221-224. doi: 10.12968/hmed.2018.79.4.221.
Operation notes are often poorly completed, potentially compromising patient care. This project was undertaken to improve the quantity, quality and clarity of information included in operation notes, and make them easier to locate within a set of patient notes.
Operation notes were audited against standards laid out in national guidelines. The time taken for staff to locate an operation note, and information within it, was then measured. The layout was re-designed, followed by a re-audit.
The number of operation notes with all measured domains completed rose from 4% to 34% (P<0.001). The mean time to locate the operation note fell from 30 to 4 seconds, and the mean time to locate all requested pieces of information within the operation note fell from 35 to 20 seconds.
The interventions have improved quality and speed of access of operation notes, but there is still room for improvement.
手术记录往往填写不完整，这可能会危及患者护理。开展该项目旨在提高手术记录中所包含信息的数量、质量和清晰度，并使其在一组患者病历中更易于查找。
对照国家指南中规定的标准对手术记录进行审核。然后测量工作人员查找手术记录及其内信息所需的时间。重新设计了布局，随后进行重新审核。
所有测量领域均填写完整的手术记录数量从4%增至34%（P<0.001）。查找手术记录的平均时间从30秒降至4秒，在手术记录中查找所有所需信息的平均时间从35秒降至20秒。
这些干预措施提高了手术记录的质量和获取速度，但仍有改进空间。
