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首页> 外文期刊>ANZ journal of surgery >Quality of handwritten surgical operative notes from surgical trainees: a noteworthy issue
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Quality of handwritten surgical operative notes from surgical trainees: a noteworthy issue

机译：手术学员手写手术手术票据的质量：一个值得注意的问题

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摘要

Background Surgical operation notes are crucial for medical record keeping and information flow in continued patient care. In addition to inherent medical implications, the quality of operative notes also has important economic and medico‐legal ramifications. Further, well‐documented records can also be useful for audit purposes and propagation of research, facilitating the improvement of delivery of care to patients. We aimed to assess the quality of surgical operation notes written by junior doctors and trainees against a set standard, to ascertain whether these standards were met. Method We undertook an audit of Urology and General Surgery operation notes handwritten by junior doctors and surgical trainees in a tertiary teaching hospital over a month period both in 2014 and 2015. Individual operative notes were assessed for quality based on parameters described by the Royal College of Surgeons of England guidelines. Results Based on the Royal College of Surgeons of England guidelines, a significant proportion of analysed surgical operative notes were incomplete, with information pertaining to the time of surgery, name of anaesthetist and deep vein thrombosis prophylaxis in particular being recorded less than 50% of the time (22.42, 36.36 and 43.03%, respectively).Overall, 80% compliance was achieved in 14/20 standards and 100% compliance was attained in only one standard. Conclusions The quality of surgical operation notes written by junior doctors and trainees demonstrated significant deficiencies when compared against a set standard. There is a clear need to educate junior medical staff and to provide systems and ongoing education to improve quality. This would involve leadership from senior staff, ongoing audit and the development of systems that are part of the normal workflow to improve quality and compliance.
机译：背景技术手术操作说明对于医疗记录保持和持续患者护理中的信息流是至关重要的。除固有的医学意义外，手术说明的质量还具有重要的经济和药物法律后果。此外，记录良好的记录也可用于审计目的和研究传播，促进对患者的关注提供的改善。我们旨在评估初级医生和受训人员对集合标准撰写的外科手术笔记的质量，以确定是否满足这些标准。 2014年和2015年的三级教学医院的初级医生和外科学员在2014年和2015年的一个月期间进行了对泌尿外科和普通外科医学的审计。根据皇家学院描述的参数，对质量评估了个人操作票据英格兰的外科医生。结果基于英格兰皇家外科医生的指导方针，分析的外科手术票据的大量分析是不完整的，与手术时的信息，麻醉师和深静脉血栓形成预防的信息，特别是记录不到50％时间（分别为22.42,36.36和43.03％）.Overall，80％的顺应性在14/20标准中实现，只有一个标准达到100％的顺应性。结论与集合标准相比，初级医生和学员撰写的外科手术票据的质量表现出显着的缺陷。明确需要教育初级医疗人员，并提供系统和正在进行的教育，以提高质量。这将涉及高级工作人员的领导，正在进行的审计和系统的发展，这些系统是正常工作流程的一部分，以提高质量和合规性。

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  • 来源
    《ANZ journal of surgery》 |2019年第3期|共4页
  • 作者

    Nzenza Tatenda C.; Manning Todd; Ngweso Simeon; Perera Marlon; Sengupta Shomik; Bolton Damien; Lawrentschuk Nathan;

  • 作者单位

    Department of Surgery Austin HospitalThe University of MelbourneMelbourne Victoria Australia;

    Department of Surgery Austin HospitalThe University of MelbourneMelbourne Victoria Australia;

    Young Urology Researchers OrganisationMelbourne Victoria Australia;

    Department of Surgery Austin HospitalThe University of MelbourneMelbourne Victoria Australia;

    Department of Surgery Austin HospitalThe University of MelbourneMelbourne Victoria Australia;

    Department of Surgery Austin HospitalThe University of MelbourneMelbourne Victoria Australia;

    Department of Surgery Austin HospitalThe University of MelbourneMelbourne Victoria Australia;

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  • 原文格式 PDF
  • 正文语种 eng
  • 中图分类 外科学;
  • 关键词

    general surgery; operation note; operation report; urology;

    机译：一般手术;操作说明;操作报告;泌尿外科;

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