Oral Pathology and Microbiology, Saveetha Institute of Medical and Technical Sciences, Saveetha Dental College and Hospitals, Saveetha University, Chennai, India.
Oral and Maxillofacial Surgery, Saveetha Institute of Medical and Technical Sciences, Saveetha Dental College and Hospitals, Saveetha University, Chennai, India.
BMC Oral Health. 2024 Sep 11;24(1):1060. doi: 10.1186/s12903-024-04811-8.
The Surgical Tool for Auditing Records scoring system [STAR] focuses on surgical record auditing with promising outcomes. It offers a structured approach to evaluating the quality of surgical notes.
This study aimed to assess the effectiveness of the STAR in evaluating oral surgical records and identifying areas for improvement in documentation practices.
The data was obtained from the Dental Information Archival Software (DIAS) of our institution. The sample size was determined using G*Power 3.1.9.4 software. Fifty consecutive oral surgery clinical records of oral squamous cell carcinoma patients were evaluated using STAR. Each record was reviewed for adherence to documentation standards including Initial Assessment (10 points), Follow-up Entries (8 points), Consent Documentation (7 points), Anesthesia Report (7 points), Surgical Log (9 points), and Discharge Synopsis (9 points). compiling a total STAR score (50 points). The data was tabulated in Google Sheets. The descriptive statistics with inter-observer agreement and the mean score were recorded.
We observed that each of the 50 records received a score of 49/50 points on the STAR. Deductions were necessary in the Operative record section due to the lack of information regarding the sutures used.
To summarize, this study emphasizes the effectiveness of the STAR scoring system in evaluating the quality of oral surgical records. Identifying deficiencies, particularly in documenting operative details, can improve the completeness and accuracy of patient records. It can ultimately enhance patient care and facilitate better communication among healthcare professionals.
外科手术记录审核评分系统（STAR）专注于外科记录审核，具有良好的效果。它提供了一种评估手术记录质量的结构化方法。
本研究旨在评估 STAR 在评估口腔外科记录和识别文档记录实践改进方面的有效性。
该数据来自我们机构的牙科信息档案软件（DIAS）。使用 G*Power 3.1.9.4 软件确定样本量。使用 STAR 评估了 50 例连续的口腔鳞状细胞癌患者的口腔外科临床记录。每个记录均根据以下标准进行审查：初始评估（10 分）、后续记录（8 分）、同意书记录（7 分）、麻醉报告（7 分）、手术日志（9 分）和出院小结（9 分），总分为 50 分。数据制表于 Google Sheets。记录了描述性统计数据、观察者间一致性和平均分数。
我们观察到，50 份记录中的每份记录均获得了 STAR 的 49/50 分。由于缺乏有关使用缝线的信息，因此在手术记录部分需要扣分。
总之，本研究强调了 STAR 评分系统在评估口腔外科记录质量方面的有效性。识别缺陷，特别是在记录手术细节方面，可以提高患者记录的完整性和准确性。最终可以改善患者的护理并促进医疗保健专业人员之间的更好沟通。
