Akasha Munzir, Alfatih Ahmmad, Mohamed Mohamedali, Acharya Yogesh, Alawy Mahmoud
Department of Vascular Surgery, University Hospital Galway, Galway, IRL.
Department of Cardiothoracic Surgery, University Hospital Galway, Galway, IRL.
Cureus. 2024 Feb 23;16(2):e54791. doi: 10.7759/cureus.54791. eCollection 2024 Feb.
Background and objective Missing information or mistakes in patients' medical records, including those related to intraoperative and postoperative information, in an operative note can have profound clinical, ethical, and medicolegal implications. Operative notes should be informative, clear, and inclusive of the necessary data and should be collated immediately following surgery. In this study, we aimed to determine the ways to improve the quality of operative notes in the field of vascular surgery. Methods In this retrospective analysis, we compared the operative notes of 32 patients in the Department of Vascular and Endovascular Surgery, University Hospital Galway, against the standard set by the Royal College of Surgeons in Ireland (RCSI) (Code of Practice for Surgeons RCSI, 2018) and presented the results to our departmental staff. To facilitate an improvement in the quality of operative notes, a structured poster checklist was designed and displayed in the operating theatre. Furthermore, a scanner was set up in the operating theatre with clear and easy-to-follow instructions for uploading the operative notes into our hospital's online and digital patient record system (EVOLVE). An explanatory video was circulated among the staff. Three months after the first cycle, two further retrospective cycles were performed. Results A total of 96 patients' operative notes were analysed. Following the intervention, a significant improvement in documentation was noted concerning the dates; procedures followed; as well as the details of surgeons, assistants, anesthetists, incisions, surgery types, operative diagnoses, complications, additional procedures, tissue details, prostheses involved, closure techniques, postoperative plans, and surgeons' signatures. We also observed a significant increase in the uploading of the operative notes in the EVOLVE system. Conclusions The quality of the operative notes improved considerably after staff education, poster display, and scanner installment in the operating theatre. It is important to have an efficient and well-structured plan to improve the process of operative note-keeping, thereby ultimately enhancing overall patient care.
背景与目的 患者病历中的信息缺失或错误，包括与手术中及术后信息相关的内容，在手术记录中可能会产生深远的临床、伦理及法医学影响。手术记录应内容详实、清晰，并包含必要数据，且应在手术后立即整理。在本研究中，我们旨在确定提高血管外科领域手术记录质量的方法。方法 在这项回顾性分析中，我们将戈尔韦大学医院血管与血管内外科32例患者的手术记录与爱尔兰皇家外科医师学院（RCSI）制定的标准（《RCSI外科医生执业规范》，2018年）进行比较，并将结果展示给我们科室的工作人员。为促进手术记录质量的提高，设计了一份结构化的海报检查表并张贴在手术室。此外，在手术室设置了一台扫描仪，并配有清晰易懂的说明，用于将手术记录上传至我院的在线数字患者记录系统（EVOLVE）。还在工作人员中传阅了一段解释性视频。在第一个周期后的三个月，又进行了另外两个回顾性周期。结果 共分析了96例患者的手术记录。干预后，在日期记录、所遵循的手术步骤、外科医生、助手、麻醉师、切口、手术类型、手术诊断、并发症、附加手术、组织细节、所涉及的假体、缝合技术、术后计划以及外科医生签名等方面的记录有了显著改善。我们还观察到EVOLVE系统中手术记录的上传量显著增加。结论 在手术室进行工作人员培训、张贴海报以及安装扫描仪后，手术记录的质量有了显著提高。制定一个高效且结构合理的计划来改进手术记录保存流程非常重要，从而最终提高整体患者护理水平。
