Singla Lakshay, Bagade Neeraj V
General Surgery, Mersey and West Lancashire Teaching Hospitals NHS Trust, Prescot, GBR.
Cureus. 2025 Aug 11;17(8):e89833. doi: 10.7759/cureus.89833. eCollection 2025 Aug.
Good operative documentation is essential for clinical communication, quality assurance, and medicolegal protection. In the United Kingdom (UK), standardized documentation for laparoscopic appendectomies has been emphasized through national quality initiatives. We conducted a two-cycle audit at a UK district general hospital to evaluate compliance with 34 recommended standards for appendectomy documentation. The first cycle retrospectively included 75 cases from May to July 2024, while the second cycle prospectively included 37 cases from September to November 2024. Between the two cycles, interventions were implemented, including a structured operative note template and staff education. Post intervention, notable improvements were observed in documentation practices, particularly in the use of the electronic system (41.8% to 76%), mesoappendix documentation (78.1% to 100%), and reporting of blood loss (1.35% to 13.6%). The audit demonstrates that simple systematic changes can significantly enhance documentation quality. Ongoing use of structured templates and regular re-auditing are recommended to maintain high standards.
良好的手术记录对于临床沟通、质量保证和医疗法律保护至关重要。在英国,通过国家质量倡议强调了腹腔镜阑尾切除术的标准化记录。我们在一家英国地区综合医院进行了两轮审计,以评估对阑尾切除术记录34项推荐标准的遵守情况。第一轮回顾性纳入了2024年5月至7月的75例病例,而第二轮前瞻性纳入了2024年9月至11月的37例病例。在两轮之间,实施了干预措施,包括结构化手术记录模板和员工教育。干预后,记录实践有了显著改善,特别是在电子系统的使用方面(从41.8%提高到76%)、阑尾系膜记录方面(从78.1%提高到100%)以及失血量报告方面(从1.35%提高到13.6%)。审计表明,简单的系统性改变可以显著提高记录质量。建议持续使用结构化模板并定期重新审计以维持高标准。