Almousa Sulaiman A
Department of Orthopedic Surgery, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam 31441, Saudi Arabia.
World J Orthop. 2025 May 18;16(5):104438. doi: 10.5312/wjo.v16.i5.104438.
Operative reports (OP-Rs) are essential for communication among healthcare providers. They require accuracy and completeness to serve as a quality indicator of patient care. Objective assessment of primary total knee replacement (TKR) OP-Rs has never been reported. Therefore, a standardized benchmark for assessment and factors affecting the completeness of TKR OP-Rs needs to be evaluated.
To evaluate the completeness rate of primary TKR OP-Rs in a teaching hospital and to assess the factors affecting completeness.
A retrospective review of 58 consecutive primary TKR OP-Rs in a tertiary teaching hospital were included in this study. We used document analysis to review the OP-Rs against a standardized list of six subsets of mandatory variables. The correlation between the percentage of completeness and the specific variables was determined.
After analyzing 58 cases, we found that the time to documentation was 1.5 hours. Out of the 52 mandatory variables, a median of 30 variables were documented yielding a completeness of 58%. Administrative, procedural, exposure, and implant variables were documented the most often, whereas clinical and process variables were most frequently left uncompleted. The documentation of the operative maneuver was variable. There was no association between the completeness of the reports and the time to documentation, documenter level, complication rate, operative duration, or length of hospital stay.
Multiple variables were left undocumented on the unstructured primary TKR OP-Rs. The completeness percentage will likely improve after the implementation of a standardized structured OP-R.
手术报告对医疗服务提供者之间的沟通至关重要。它们需要准确和完整，才能作为患者护理质量的指标。目前尚无关于初次全膝关节置换术（TKR）手术报告的客观评估的报道。因此，需要评估TKR手术报告评估的标准化基准以及影响其完整性的因素。
评估一家教学医院初次TKR手术报告的完整率，并评估影响完整性的因素。
本研究纳入了对一家三级教学医院连续58份初次TKR手术报告的回顾性分析。我们使用文件分析，对照一份由六个子集的强制性变量组成的标准化列表来审查手术报告。确定了完整率与特定变量之间的相关性。
分析58例病例后，我们发现记录时间为1.5小时。在52个强制性变量中，中位数为30个变量被记录，完整率为58%。行政、手术步骤、手术暴露和植入物变量记录得最频繁，而临床和手术过程变量最常未完成。手术操作的记录情况各不相同。报告的完整性与记录时间、记录者级别、并发症发生率、手术持续时间或住院时间之间没有关联。
在非结构化的初次TKR手术报告中，多个变量未被记录。实施标准化的结构化手术报告后，完整率可能会提高。
