Alnour Ammar Alemam Diab, Hussien Mirghani E, Alhaj Ahmed, Elhassan Osman Faroug Mohammedosman, Eltahir Ahmed, Emam Mohamed Omer, Abdalla MohammedElhassan
Trauma and Orthopedics, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, GBR.
Trauma and Orthopedics, Gezira Traumatology Center, Wad Madani, SDN.
Cureus. 2025 Aug 6;17(8):e89492. doi: 10.7759/cureus.89492. eCollection 2025 Aug.
High-quality operative notes are crucial for patient safety, continuity of care, and medico-legal protection. Despite established Royal College of Surgeons (RCS) guidelines, audits globally reveal persistent deficiencies in surgical documentation. This study assessed the quality of operative notes in the Orthopedic Surgery Department at Gezira Traumatology Center, Wad Madani Teaching Hospital, Sudan, and evaluated the impact of targeted interventions.
A clinical audit was conducted in two cycles (in July 2023 and then three months post-intervention). In the first cycle, 23 randomly selected orthopedic operative notes were retrospectively audited against 14 RCS documentation parameters. Root cause analysis identified key deficiencies. A multi-faceted intervention was implemented, including staff education, a standardized RCS-aligned template, visual reminders, and a feedback mechanism. The second cycle re-audited 23 notes using the same criteria. Data were analyzed using descriptive statistics.
Pre-intervention, compliance was high for procedure (95.7%), diagnosis (95.7%), and signature (100%), but critically low for theatre anesthetist's name (4.3%), anticipated blood loss. (13%), and antibiotic prophylaxis (8.7%). Post-intervention, significant improvements were noted in documenting the anesthetist's name (82.6%), anticipated blood loss (82.6%), complications (91.3%), and antibiotic prophylaxis (69.6%). However, unexpected declines were observed in documenting prosthesis identification (from 87% to 26.1%) and tissue details (from 87% to 65.2%). High-compliance areas generally remained stable.
Implementing a standardized operative note template based on RCS guidelines, combined with education and feedback, significantly improved the completeness of critical documentation elements in orthopedic operative notes. The decline in documenting prosthesis and tissue details highlights the need for focused reinforcement and ongoing monitoring to achieve consistent, comprehensive compliance. Standardized templates are highly effective tools for enhancing surgical documentation quality.
高质量的手术记录对于患者安全、护理连续性和医疗法律保护至关重要。尽管有皇家外科医学院（RCS）既定的指南，但全球范围内的审计显示手术记录中仍存在持续的缺陷。本研究评估了苏丹瓦德迈达尼教学医院盖齐拉创伤中心骨科手术科室的手术记录质量，并评估了针对性干预措施的影响。
进行了两个周期的临床审计（2023年7月，然后在干预后三个月）。在第一个周期中，对随机抽取的23份骨科手术记录进行回顾性审计，对照14项RCS记录参数。根本原因分析确定了关键缺陷。实施了多方面的干预措施，包括员工教育、与RCS标准一致的标准化模板、视觉提示和反馈机制。第二个周期使用相同标准对23份记录进行重新审计。使用描述性统计方法分析数据。
干预前，手术步骤（95.7%）、诊断（9%.7%）和签名（100%）的合规率较高，但麻醉师姓名（4.3%）、预计失血量（13%）和抗生素预防（8.7%）的合规率极低。干预后，麻醉师姓名（82.6%）、预计失血量（82.6%）、并发症（91.3%）和抗生素预防（69.6%）的记录有显著改善。然而，在记录假体标识（从87%降至26.1%）和组织细节（从87%降至65.2%）方面出现了意外下降。高合规率领域总体保持稳定。
基于RCS指南实施标准化手术记录模板，结合教育和反馈，显著提高了骨科手术记录中关键记录要素的完整性。假体和组织细节记录的下降凸显了需要集中强化和持续监测，以实现一致、全面的合规。标准化模板是提高手术记录质量的高效工具。
