Muneeb Muhammad Danish, Baig Mirza Agha Naushad, Kamran Muhammad, Qudratullah Shafaatullah, Arain Muhammad Saddique
Muhammad Danish Muneeb, Baqai Medical University, Karachi, Pakistan.
Mirza Agha Naushad Baig, Baqai Medical University, Karachi, Pakistan.
Pak J Med Sci. 2024 Sep;40(8):1837-1840. doi: 10.12669/pjms.40.8.9443.
To evaluate the quality and standard of hand-written operative notes in a teaching institute.
This prospective study was carried out in the department of surgery, Fatima Hospital, Baqai Medical University, from January 2023 till May 2023. One hundred fifty operative notes from general surgery domain were considered. These notes were evaluated according to the guidelines of Royal College of Surgeons, with added-on a few variables by the author.
All 150 notes were handwritten. Resident surgeon wrote the operative notes under the supervision of primary surgeon. There was a deficiency in mentioning medical record number, procedure starting time and duration of surgery. An important statement about the hemostasis is that it is secured-per-operatively was not documented. The residents were reluctant to explain the surgical procedures diagrammatically. The operative room number was missing in all notes. Post operative instructions lacked the information for nothing per oral, blood pressure, temperature, pulse rate, and input and output charting.
It is observed that the operative surgical notes were however explainable about the procedure, but quality and standard was not matchable with that of Royal College of Surgeons notes. Hence, a lack of formal training for the resident surgeons in operative notes writing was observed. This study is a thought provoker to the surgeons and a guide to resident trainees, and hospital management to provide a handful operative notes writing theme in the form of performa provided in the department.
评估一所教学机构中手写手术记录的质量和标准。
这项前瞻性研究于2023年1月至2023年5月在巴基医科大学法蒂玛医院外科进行。纳入了150份普通外科领域的手术记录。这些记录根据皇家外科医学院的指南进行评估，作者还增加了一些变量。
所有150份记录均为手写。住院医师在主刀医生的监督下书写手术记录。在提及病历号、手术开始时间和手术时长方面存在不足。关于止血的一项重要陈述，即术中止血已妥善完成，未被记录。住院医师不愿意用图表解释手术过程。所有记录中均缺少手术室编号。术后医嘱缺乏关于禁食、血压、体温、脉搏率以及出入量记录的信息。
据观察，手术记录虽能对手术过程作出解释，但其质量和标准与皇家外科医学院的记录不匹配。因此，发现住院医师在手术记录书写方面缺乏正规培训。本研究对外科医生是一种启发，对住院医师培训生以及医院管理部门是一种指导，促使其以科室提供的表格形式提供详尽的手术记录书写模板。
