PDF(Pubmed)
Abstract：
UNASSIGNED: Operation notes are important for care in surgical patients. The objectives of this study were to analyze the emergency general surgery (EGS) operation note documentation in accordance with the Royal College of Surgeons of England (RCSEng) guidelines and to assess the impact of creating awareness of the guidelines and effect of a new proforma.
UNASSIGNED: A retrospective review of 50 EGS operation notes was conducted between December 2019 and March 2020 and compared to RCSEng guidelines. Education was delivered on the importance of documentation in accordance with RCSEng guidelines. A new electronic proforma was introduced. A further 50 EGS operation notes were analysed between August 2020 and December 2020.
UNASSIGNED: One hundred operation notes were reviewed, and each given a score out of 19. Our interventions showed significant improvement to the average score (15.64 vs 17.96; p <0.001). Within the second cycle, there was a statistically significance difference when comparing electronic to handwritten notes (18.55 vs 17.50; p= 0.001).
UNASSIGNED: Implementation of the new proforma showed improvement in operation note documentation when compared to the RCSEng standard. Therefore, this study emphasizes the need for surgeons to familiarize themselves with the current guidelines.
UNASSIGNED: A retrospective review of 50 EGS operation notes was conducted between December 2019 and March 2020 and compared to RCSEng guidelines. Education was delivered on the importance of documentation in accordance with RCSEng guidelines. A new electronic proforma was introduced. A further 50 EGS operation notes were analysed between August 2020 and December 2020.
UNASSIGNED: One hundred operation notes were reviewed, and each given a score out of 19. Our interventions showed significant improvement to the average score (15.64 vs 17.96; p <0.001). Within the second cycle, there was a statistically significance difference when comparing electronic to handwritten notes (18.55 vs 17.50; p= 0.001).
UNASSIGNED: Implementation of the new proforma showed improvement in operation note documentation when compared to the RCSEng standard. Therefore, this study emphasizes the need for surgeons to familiarize themselves with the current guidelines.
摘要：
■手术注意事项对于手术患者的护理很重要。本研究的目的是根据英国皇家外科医学院（RCSEng）指南分析急诊普外科（EGS）手术说明文件，并评估提高对指南的认识和新形式效果的影响。
■在2019年12月至2020年3月之间对50份EGS操作说明进行了回顾性审查，并与RCSEng指南进行了比较。根据RCSEng准则，就文件的重要性进行了教育。介绍了一种新的电子形式。在2020年8月至2020年12月期间，又分析了50份EGS操作说明。
■审查了一百个操作说明，每个人都得了19分。我们的干预措施显示平均得分显着改善（15.64vs17.96；p<0.001）。在第二个周期内，将电子笔记与手写笔记进行比较时，差异有统计学意义（18.55vs17.50；p=0.001）。
■与RCSEng标准相比，新形式的实施显示了操作说明文档的改进。因此,这项研究强调外科医生需要熟悉现行指南.
■在2019年12月至2020年3月之间对50份EGS操作说明进行了回顾性审查，并与RCSEng指南进行了比较。根据RCSEng准则，就文件的重要性进行了教育。介绍了一种新的电子形式。在2020年8月至2020年12月期间，又分析了50份EGS操作说明。
■审查了一百个操作说明，每个人都得了19分。我们的干预措施显示平均得分显着改善（15.64vs17.96；p<0.001）。在第二个周期内，将电子笔记与手写笔记进行比较时，差异有统计学意义（18.55vs17.50；p=0.001）。
■与RCSEng标准相比，新形式的实施显示了操作说明文档的改进。因此,这项研究强调外科医生需要熟悉现行指南.
