Hassan Ibrahim Hussam Mohamed, Abdelrahman Zeineldeen Ali Abdellateef, Mohamed Mohamed Alameen Mahmood Abdalmonem, Ahmed Abdullah Izzut Awad, Mahmoud Saeed Heyam Abd Elsalam, Osman Khalid Mohamed Fawzi, Mahmoud Saeed Hadeel Abd Alsalam, Morsal Maali Mohammed Hassan, Ali Bitay Ali Suliman, Ahmed Mohammed Aymen Abdelhakim
General Surgery, Doka Hospital, Elgadarif, SDN.
Cureus. 2024 Oct 26;16(10):e72441. doi: 10.7759/cureus.72441. eCollection 2024 Oct.
Background Operating notes are crucial in surgical practice for post-operative care, future medical reference, and legal needs. They provide vital details about the procedure, guaranteeing patient safety and improving communication among medical staff. These notes include patient health status, surgical method, operation results, problems, and post-surgery plans. Established protocols for recording surgical operative notes are essential for medical education, research, and quality improvement efforts. The audit aimed to evaluate and enhance Doka Hospital's surgical operation notes, focusing on their quality, completeness, and potential areas for development. The audit aimed to apply necessary adjustments to raise standards and ensure high standards in medical treatment. Material and methods This retrospective-prospective study analyzed surgical postoperative notes from Doka Hospital's archives, following the implementation of a new format based on guidelines set by the Royal College of Surgeons of England. Staff training sessions were conducted to facilitate adoption. The audit population included surgical operative notes from the departments of general surgery and obstetrics and gynecology. The study collected 200 surgical operative notes, with 100 notes in the first cycle and 100 notes in the second cycle. Data was collected from the General Surgery and Obstetrics and Gynaecology departments using a predefined checklist, followed by analysis using the Microsoft Excel Sheets program (Microsoft Corporation, Redmond, USA). Ethical clearance was obtained from the ethical committee of Doka Hospital. The audit population consisted of 71 beds in a busy rural hospital with a majority of cases involving obstetrics and one-day surgical operations. Results Doka Hospital's surgical operative note review showed a significant improvement in documentation quality following a revised structure based on the Royal College of Surgeons of England's recommendations. Compliance with the criteria improved from 50.5% in the first cycle to 82.5% in the second cycle. Notable progress was made in date and time documentation, with a 96% increase in the second cycle. The proportion of anaesthetists' names also rose from 60% to 90%. The accuracy of recording surgical operation details increased from 87% to 94%. Documenting operational results, issues, and tissue removal also improved. Factors like the identity of the prosthesis or materials used remained unchanged in both cycles. Conclusion The introduction of a uniform style for recording surgical operational notes, together with focused training sessions, greatly improved the quality of surgical documentation at Doka Hospital.
手术记录对于术后护理、未来医学参考以及法律需求在外科手术实践中至关重要。它们提供了有关手术过程的重要细节，保障患者安全并改善医护人员之间的沟通。这些记录包括患者健康状况、手术方法、手术结果、问题以及术后计划。建立记录手术记录的规范对于医学教育、研究以及质量改进工作至关重要。此次审核旨在评估并改进多卡医院的手术记录，重点关注其质量、完整性以及潜在的改进领域。审核旨在进行必要调整以提高标准并确保医疗高标准。
这项回顾性-前瞻性研究分析了多卡医院档案中的手术术后记录，采用了基于英国皇家外科医学院制定的指南的新格式。开展了员工培训课程以促进采用。审核对象包括普通外科和妇产科的手术记录。该研究收集了200份手术记录，第一周期100份，第二周期100份。使用预定义清单从普通外科和妇产科收集数据，随后使用Microsoft Excel Sheets程序（美国雷德蒙德微软公司）进行分析。获得了多卡医院伦理委员会的伦理批准。审核对象是一家繁忙的乡村医院的71张病床，大多数病例涉及产科和一日手术。
多卡医院的手术记录审核显示，根据英国皇家外科医学院的建议修订结构后，文档质量有显著提高。符合标准的比例从第一周期的50.5%提高到了第二周期的82.5%。日期和时间记录方面取得了显著进展，第二周期增加了96%。麻醉师姓名的记录比例也从60%提高到了90%。手术操作细节记录的准确性从87%提高到了94%。手术结果、问题以及组织切除的记录也有所改善。假体或使用材料的标识等因素在两个周期中均未改变。
引入统一的手术记录记录风格以及针对性的培训课程，极大地提高了多卡医院手术文档的质量。
