背景彻底和精确的手术注释在病人护理中起着至关重要的作用,促进医疗团队之间的沟通,并作为法律目的的重要文件。不良的文档可能会危害患者安全和所提供的护理质量。使用标准化指南,如公认的外科组织认可的,对于确保一致和详细的记录保存至关重要。本研究旨在评估术后注意事项与既定指南的一致性,目的是加强医疗保健环境中的文档实践。目的本研究旨在评估术后手术记录的质量和全面性,并评估其与既定的手术文件指南的一致性。特别关注在外科实践中遵守公认的标准。方法这项横断面审核评估了白沙瓦开伯尔教学医院普外科病房的150份手术说明(79份实施前和71份实施后的皇家外科医学院(RCS)指南),巴基斯坦。数据包括围手术期发现,手术诊断,团队信息,操作细节,并发症,程序,假肢,关闭,DVT预防,超时,术后医嘱,和签名。结果实施后,围手术期发现见于68份(95.7%)笔记中,与实施前的56(70.8%)相比。手术诊断始终从65(82.3%)增加到69(97.2%)。实施后,操作类型,date,和时间一致包含在67张(94.4%)票据中。并发症,额外的程序,组织改变激增至66(92.9%),64(90.1%),和60(84.5%),分别。修复和闭合技术分别为65例(91.5%)和66例(92.9%)。68例(95.8%)记录了深静脉血栓形成(DVT)的预防和“超时”。术后顺序和签名改善到70(98.6%)和69(97.2%),分别。结论我们的研究揭示了RCS指南实施对手术注意事项文件的显着积极影响。在围手术期发现等基本组成部分中发现了改善,诊断,团队详细信息,并发症,程序,还有更多.这些增强具有深远的影响,加强患者护理并确保医疗保健提供者之间的清晰沟通,所有这些都在医疗法律事务中发挥着至关重要的作用。通过采用RCS指南,医疗机构致力于更高的文档标准,最终支持良好的临床治理。
Background Thorough and precise operative notes play a vital role in patient care, facilitating communication among healthcare teams and serving as essential documents for legal purposes. Poor
documentation can jeopardize patient safety and the quality of care provided. The use of standardized guidelines, such as those endorsed by recognized surgical organizations, is crucial to ensure consistent and detailed record-keeping. This study aims to assess the alignment of postoperative notes with established guidelines, with the goal of enhancing
documentation practices in the healthcare setting. Objectives This study aimed to evaluate the quality and comprehensiveness of postoperative surgical notes and assess their alignment with established guidelines for surgical documentation, specifically focusing on adherence to recognized standards in surgical practice. Methods This cross-sectional audit assessed 150 operative notes (79 pre-implementation and 71 post-implementation of the Royal College of Surgeons (RCS) guidelines) in the General Surgery Unit at Khyber Teaching Hospital Peshawar, Pakistan. Data included peri-operative findings, operative diagnosis, team information, operational details, complications, procedures, prosthesis, closure, DVT prophylaxis, time out, postoperative orders, and signatures. Results Post-implementation, peri-operative findings were noted in 68 (95.7%) notes, compared to 56 (70.8%) pre-implementation. Operative diagnosis consistently increased from 65 (82.3%) to 69 (97.2%). Post-implementation, operation type, date, and time were consistently included in 67 (94.4%) notes. Complications, additional procedures, and tissue alterations surged to 66 (92.9%), 64 (90.1%), and 60 (84.5%), respectively. Prosthesis and closure techniques were recorded in 65 (91.5%) and 66 (92.9%). Deep vein thrombosis (DVT) prophylaxis and \"time out\" were documented in 68 (95.8%) notes. Postoperative orders and signatures improved to 70 (98.6%) and 69 (97.2%), respectively. Conclusion Our study revealed the significant positive impact of RCS
guideline implementation on operative note
documentation. Improvements were noted in essential components such as peri-operative findings, diagnosis, team details, complications, procedures, and more. These enhancements have far-reaching implications, bolstering patient care and ensuring clear communication among healthcare providers, all while serving a vital role in medico-legal matters. By adopting the RCS
guidelines, healthcare institutions commit to a higher
documentation standard, ultimately supporting good clinical governance.