Mafrachi Baraa, Al-Ani Abdallah, Al Debei Ashraf, Elfawair Mohamad, Al-Somadi Hussien, Shahin Mohammed, Alda'as Yazan, Ajlouni Jihad, Bani Hani Amjad, Abu Abeeleh Mahmoud
Orthopaedics and Trauma, The University of Jordan, Amman, JOR.
Department of Research, King Hussein Medical Center, Amman, JOR.
Cureus. 2021 Nov 1;13(11):e19193. doi: 10.7759/cureus.19193. eCollection 2021 Nov.
Aims Due to the significant value held by medical records in terms of influencing patient care and medico-legal cases, this study aimed to investigate the quality of surgical notes and their improvement through periodic auditing during a six-year period at a major tertiary hospital. Methodology This study retrospectively evaluated surgical records of patients undergoing elective orthopedic surgeries at Jordan University Hospital from 2016 to 2021 using the Surgical Tool for Auditing Records (STAR) validated questionnaire. This questionnaire is composed of six distinct sections aimed to quantify the quality of medical records and demonstrate their associated deficiencies. Pre- and post-audit STAR scores were analyzed using the two independent sample t-test on Statistical Package for Social Sciences (SPSS) version 23.0 (IBM Corp. Armonk, NY). Results A total of 454 records were randomly selected and evaluated using the STAR questionnaire. There was an overall significant trend of improvement in the quality of records in all evaluated years compared to the 2016 baseline. The most pronounced improvements were in the records of 2021 as compared to the 2016 baseline (97.4 ± 0.7 vs. 94.3 ± 1.6; p:<0.05), in which the Initial Clerking, Subsequent Entries, and Operative Record domains had the most significant magnitude of change. The Consent and Anesthesia domains plateaued over the study's period in terms of overall quality. The most improved STAR domain was the Discharge Summary domain, in which four subsections (follow-up, diagnosis, complications, and medications on discharge) had significant STAR score increases (all; p:<0.05). Conclusion Our study implies that simple measures, including personnel education and training and periodic auditing, are effective measures in increasing the quality of surgical records. High-quality medical records need to be sustained and continuously improved, as they contribute to better health care, promote research, and contribute to economic gains through cost-effective practices.
目的 由于病历在影响患者护理和医疗法律案件方面具有重大价值，本研究旨在调查一家大型三级医院在六年期间手术记录的质量及其通过定期审核得到的改善情况。
方法 本研究使用经过验证的手术记录审核工具（STAR）问卷，回顾性评估了2016年至2021年在约旦大学医院接受择期骨科手术患者的手术记录。该问卷由六个不同部分组成，旨在量化病历质量并展示其相关缺陷。使用社会科学统计软件包（SPSS）23.0版（IBM公司，纽约州阿蒙克）的两独立样本t检验分析审核前和审核后的STAR评分。
结果 共随机选择454份记录并使用STAR问卷进行评估。与2016年基线相比，所有评估年份的记录质量总体上都有显著改善趋势。与2016年基线相比，2021年的记录改善最为显著（97.4±0.7对94.3±1.6；p<0.05），其中初始病历记录、后续记录和手术记录领域的变化幅度最大。同意书和麻醉领域在研究期间的总体质量趋于平稳。改善最明显的STAR领域是出院小结领域，其中四个子部分（随访、诊断、并发症和出院用药）的STAR评分有显著提高（均为；p<0.05）。
结论 我们的研究表明，包括人员教育和培训以及定期审核在内的简单措施是提高手术记录质量的有效措施。高质量的病历需要持续保持并不断改进，因为它们有助于提供更好的医疗服务、促进研究，并通过具有成本效益的做法带来经济效益。
