巴基斯坦医学科学院（P.I.M.S.）普外科手术记录审核。我们是否遵循英国皇家外科学院指南？
An audit of operative notes in general surgery at Pakistan Institute of Medical Sciences (P.I.M.S.), Pakistan. Do we follow the Royal College of Surgeons (England) guidelines?
机构信息
Sulaman Al Habib Medical Group, Riyadh, Saudi Arabia.
出版信息
J Pak Med Assoc. 2020 Mar;70(3):491-493. doi: 10.5455/JPMA.8686.
OBJECTIVE
To evaluate operative notes in the light of a standard guideline, and to establish a new more precise proforma for future documentation.
METHODS
The retrospective study was conducted at the Pakistan Institute of Medical Sciences, Islamabad, Pakistan, and comprised audit of consecutive General Surgery elective operation theatre notes from October 2015 to November 2015 according to Royal College of Surgeons (England) guidelines 2014. After the audit, all the doctors were educated about the completion of operation notes and an experimental operation notes template was designed and implemented. Re-audit was done.
RESULTS
A total of 60 operation notes were audited, and of the 20 parameters in the checklist, only 2(10%) were filled up at all times; surgeon's name and procedure. In the remaining 18(90%) parameters, the value ranged from 0% to 98.3%. Re-audit showed 100% note-taking across all the 20 parameters.
CONCLUSIONS
The new proforma for operative notes allowed no room for error or missed entries.
目的
根据标准指南评估手术记录，并为未来的文件记录制定新的更精确的表格。
方法
该回顾性研究在巴基斯坦伊斯兰堡的巴基斯坦医学科学院进行，根据 2014 年皇家外科学院（英国）指南，对 2015 年 10 月至 11 月期间连续的普通外科选择性手术室记录进行审核。审核后，所有医生都接受了手术记录完成情况的教育，并设计和实施了一个实验性的手术记录模板。进行了重新审核。
结果
共审核了 60 份手术记录，在检查表的 20 个参数中，只有 2 个（10%）始终填写完整；外科医生的姓名和手术程序。在其余 18 个（90%）参数中，数值范围从 0%到 98.3%。重新审核显示，所有 20 个参数的记录率均为 100%。
结论
新的手术记录表格不允许出现错误或遗漏条目。
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