背景:手术说明代表了外科手术的关键记录,涵盖整个操作中遇到的全面细节。认识到全面文件的重要性,皇家外科医学院(RCS)制定了良好的外科实践指南,它强调准确记录每个程序,并为每个操作说明指定必要的参数。这些指南有助于保持高标准的手术护理和患者安全。
方法:2022年3月12日至5月28日,在Gezira骨科手术和创伤中心(GCOST)对88例股骨颈骨折的骨科手术操作记录进行了回顾性回顾。审查根据RCS指南评估了18个参数。使用统计产品和服务解决方案(SPSS,版本25.0;IBMSPSSStatisticsforWindows,Armonk,NY),这有助于全面的数据检查。
结果:37例(42.05%),手术笔记是由一名医务人员写的。29例(32.95%),一位骨科住院医师撰写了这些笔记。一位专家记录了21例(23.86%)的笔记,一名顾问在一个案例中写下了笔记(1.14%)。超过90%的笔记包括外科医生和助理的名字,过程名称,手术诊断,操作程序,假体细节,深静脉血栓形成(DVT)和抗生素预防,和签名。剧院麻醉师的名字,选修/紧急细节,所有注释中都没有其他有原因的程序。不到50%的笔记记录了手术时间,切口类型,手术发现,预期失血,闭合技术细节,和并发症。
结论:该研究强调了操作说明中的缺点,强调有必要采取培训措施,以加强医务人员和骨科学员的记录。实施符合RCS标准的结构化模板可以提高操作说明的全面性和一致性,有效解决现有的差异。定期审计和反馈会议对于识别和纠正持续存在的问题至关重要。建议安排讲习班和研讨会,对医务人员和受训人员进行有效记笔记和全面记录程序的技能教育。
BACKGROUND: Operative notes represent the critical record of a surgical procedure, encompassing comprehensive details encountered throughout the operation. Recognizing the importance of comprehensive documentation, the Royal College of Surgeons (RCS) developed the Good Surgical Practice guidelines, which emphasize accurately recording every procedure and specifying the necessary parameters for each operative note. These guidelines help maintain high
standards of surgical care and patient safety.
METHODS: A retrospective review of 88 orthopaedic surgery operative notes for fracture neck of femurs was conducted at Gezira Centre for Orthopedic Surgery and Traumatology (GCOST) from March 12 to May 28, 2022. The review assessed 18 parameters against RCS guidelines. Statistical analysis was performed using Statistical Product and Service Solutions (SPSS, version 25.0; IBM SPSS Statistics for Windows, Armonk, NY), which facilitated comprehensive data examination.
RESULTS: In 37 cases (42.05%), the operation notes were written by a medical officer. In 29 cases (32.95%), an orthopaedic resident authored the notes. A specialist documented the notes in 21 cases (23.86%), and a consultant wrote the notes in one case (1.14%). Over 90% of the notes included surgeon and assistant names, procedure names, operative diagnoses, operative procedures, prosthesis details, deep vein thrombosis (DVT) and antibiotic prophylaxis, and signatures. The name of the theatre anaesthetist, elective/emergency details, and additional procedures with reasons were absent in all notes. Less than 50% of the notes documented the time of the procedure, type of incision, operative findings, anticipated blood loss, closure technique specifics, and complications.
CONCLUSIONS: The study emphasizes the shortcomings in the operating notes, underscoring the necessity for training initiatives to enhance the recording by medical officers and orthopaedic trainees. Implementing structured templates that adhere to RCS
standards can improve the comprehensiveness and consistency of operating notes, effectively resolving existing discrepancies. Regular audits and feedback sessions are essential for identifying and rectifying persistent issues. It is recommended to arrange workshops and seminars to educate medical officials and trainees on the skills of efficient note-taking and thorough documentation procedures.