Elhadi Bakheet Osama, Muhammed Abubakr, Mohamed Ahmed, Abdalla Ahmed Salih Ahmed, Abdalrahman Ali Abdalrahman Abdalhalim, Ahmed Sayed Ahmed Salah, Farah Hassan Nada Hassan, Elnour Elawad Mohammed Eltayeb, Mohammedali Abdelrhman Mohammed Khalid, Eltayeb Abdelnour Ayman Adil
General Surgery, Dongola Teaching Hospital, Dongola, SDN.
General Surgery, University of Gezira, Wad Madani, SDN.
Cureus. 2024 Oct 2;16(10):e70726. doi: 10.7759/cureus.70726. eCollection 2024 Oct.
Background Surgical operative notes are essential for patient care and legal documentation. However, inconsistencies in the quality of these notes at Dongola Teaching Hospital, Sudan, highlighted the need for improvement. In line with guidelines from the Royal College of Surgeons of England (RCSEng), this study aimed to enhance the documentation practices in the hospital by implementing a standardized format. Methods A retrospective audit was conducted over three months at the General Surgery Department of Dongola Training Hospital. In the first audit cycle, 81 surgical notes were assessed, revealing significant deficiencies in adherence to RCSEng standards. An intervention was introduced, including a standardized template, training for surgeons, and widespread dissemination of the new format. A second audit cycle followed to assess improvements. Results In the first audit cycle, adherence to documentation standards was 50.3%, with missing or incomplete information in key areas. After the intervention, adherence improved to 71.9%. Notable improvements included documentation of extra procedures (18% to 100%), prosthesis details (0% to 100%), and antibiotic prophylaxis (71% to 97%). However, a slight decline was observed in postoperative care instructions, dropping from 100% to 90%. Conclusion The introduction of a standardized template and training significantly improved the quality of surgical documentation. Continuous efforts are necessary to maintain these improvements, particularly in areas where adherence remains suboptimal, such as postoperative care instructions.
手术记录对于患者护理和法律文件记录至关重要。然而，苏丹栋古拉教学医院这些记录的质量参差不齐，凸显了改进的必要性。根据英国皇家外科医学院（RCSEng）的指南，本研究旨在通过实施标准化格式来改善该医院的文件记录做法。方法：在栋古拉培训医院普通外科进行了为期三个月的回顾性审计。在第一个审计周期中，评估了81份手术记录，发现其在遵守RCSEng标准方面存在重大缺陷。随后引入了一项干预措施，包括标准化模板、对外科医生的培训以及新格式的广泛传播。接着进行了第二个审计周期以评估改进情况。结果：在第一个审计周期中，文件记录标准的遵守率为50.3%，关键领域存在信息缺失或不完整的情况。干预措施实施后，遵守率提高到了71.9%。显著的改进包括额外手术记录（从18%提高到100%）、假体细节记录（从0%提高到100%）以及抗生素预防记录（从71%提高到97%）。然而，术后护理指导方面略有下降，从100%降至90%。结论：引入标准化模板和培训显著提高了手术文件记录的质量。需要持续努力来维持这些改进，特别是在遵守情况仍不理想的领域，如术后护理指导。
