Ege University School of Medicine, Department of Surgery, Turkey.
Ege University School of Medicine, Department of Surgery, Turkey.
Asian J Surg. 2020 Jul;43(7):755-758. doi: 10.1016/j.asjsur.2019.10.002. Epub 2019 Oct 22.
Both from a medical and legal point of view, the quality of operative notes are important. In this study we hypothesized that the quality of operation notes could be improved by audit, education session and using a proforma.
A total of 150 operation notes were audited for compliance with the Royal College of Surgeons guidelines. Results were announced in-clinic training session and guidelines were discussed. An aide-memoire containing guideline parameters placed in the operating theaters. After eight months, operation reports were re-audited on an equal number of patients. An operative note proforma was developed and third audit was carried out. The results of each audit were compared.
In the first audit, it was found that fourteen parameters were written with more than 90% accuracy. The first audit revealed seven poor areas in documentation: time of operation (0%), identification of emergency/elective procedure (0%), identification of any prosthesis or devices used (65.3%), details of closure technique (36.6%), name of anesthesiologist (0%), patient position (1.3%), and amount of bleeding (0%). In the second audit there was an incomplete, but significant improvement in these seven parameters (28%, 28.6%, 82%, 75.3%, 31.3%, 32%, and 34% respectively). Following introduction of the proforma; third audit cycle demonstrated a clear improvement in operation note documentation with at least 80% compliance in all parameters.
This study revealed that the accuracy of the operating room documents can be improved through audits, education of surgeon and using proformas. The use of proforma provides much better results.
从医学和法律的角度来看，手术记录的质量都很重要。在这项研究中，我们假设通过审核、教育会议和使用表格可以提高手术记录的质量。
共审核了 150 份手术记录，以符合皇家外科医师学院的指南。结果在院内培训会议上公布，并讨论了指南。在手术室放置包含指南参数的便签，作为辅助记忆。八个月后，对同等数量的患者重新审核手术报告。开发了手术记录表格，并进行了第三次审核。比较了每次审核的结果。
在第一次审核中，发现有十四个参数的书写准确率超过 90%。第一次审核发现文档记录中有七个不足之处：手术时间（0%）、确定紧急/择期手术（0%）、确定使用的任何假体或设备（65.3%）、详细的关闭技术（36.6%）、麻醉师姓名（0%）、患者体位（1.3%）和出血量（0%）。在第二次审核中，这七个参数有了不完整但显著的改进（分别为 28%、28.6%、82%、75.3%、31.3%、32%和 34%）。引入表格后；第三次审核周期显示，在所有参数中，手术记录文档的记录有了明显的改善，至少有 80%的符合率。
本研究表明，通过审核、外科医生教育和使用表格，可以提高手术室文件的准确性。使用表格可以提供更好的结果。
