Nyamulani Nohakhelha, Mulwafu Wakisa
Queen Elizabeth Central Hospital, Department of Surgery, Blantyre, Malawi.
University of Malawi, College of Medicine, Department of Surgery, Chichiri, Blantyre.
Malawi Med J. 2018 Jun;30(2):86-89. doi: 10.4314/mmj.v30i2.6.
Operative note writing is one of the fundamental parts in surgical practice. Accurate documentation is critical, to be of value when used for postoperative care, research, academic purposes and medical legal clarity. Although guidelines guiding surgeons on how to write operative notes exist, deficiencies are noted worldwide.
To assess quality of hand-written operative notes in surgical unit at Queen Elizabeth Central Hospital (QECH) using the RCSEng guidelines as a standard.
To identify key areas of weaknesses, a sole observer in this study assessed prospectively the quality of operative notes in our setting. The audit loop was completed after adoption of new interventions.
Sixty-seven percent of the notes were written by trainees in both audits. Key areas of missing data were on time of performing the operation, urgency, estimated blood loss, complications and extra procedure in the first audit, with a frequency of 0%, 2%, 14%, 38% and 11% respectively. The results improved significantly to 62%, 84%, 62%, 70%and 32% respectively [p<0.05] in the second audit. Half of the postoperative care instructions were inadequate with 29% of the notes partially illegible or completely illegible.
The study identifies significant deficiencies in our operative note writing. Surgeon's education, use of detailed pro formas with heading prompts and aide memoirs for vital information play a major role in better note completion. The role of electronic health records is highlighted.
手术记录书写是外科手术实践的基本组成部分之一。准确的记录至关重要，在用于术后护理、研究、学术目的以及医疗法律明晰性方面具有重要价值。尽管存在指导外科医生如何书写手术记录的指南，但全球范围内仍存在不足之处。
以英国皇家外科学院（RCSEng）指南为标准，评估伊丽莎白女王中央医院（QECH）外科病房手写手术记录的质量。
为确定关键薄弱环节，本研究由一名观察者前瞻性地评估我们科室手术记录的质量。在采取新的干预措施后完成审核循环。
在两次审核中，67%的记录由实习医生书写。第一次审核中，缺失数据的关键领域包括手术时间、紧急程度、估计失血量、并发症和额外操作，其出现频率分别为0%、2%、14%、38%和11%。在第二次审核中，这些结果分别显著改善至62%、84%、62%、70%和32%[p<0.05]。一半的术后护理指导不充分，29%的记录部分难以辨认或完全无法辨认。
该研究发现我们的手术记录书写存在重大缺陷。外科医生的教育、使用带有标题提示的详细表格以及重要信息的备忘清单在更好地完成记录方面起着重要作用。强调了电子健康记录的作用。
