背景和客观患者病历中的信息缺失或错误,包括与术中和术后相关的信息,在手术记录中可以有深刻的临床,伦理,和法医学意义。操作说明应提供信息,clear,并包含必要的数据,应在手术后立即进行整理。在这项研究中,我们旨在确定提高血管外科领域手术记录质量的方法。方法回顾性分析,我们比较了32例血管外科和血管内外科患者的手术效果,戈尔韦大学医院,与爱尔兰皇家外科医学院(RCSI)(外科医师实践守则RCSI,2018年),并将结果提交给我们的部门工作人员。为了促进操作笔记质量的提高,手术室设计并展示了一份结构化的海报清单。此外,我们在手术室设置了一个扫描仪,提供清晰易懂的操作说明,将手术记录上传到我们医院的在线和数字患者记录系统(EVOLVE).在工作人员中散发了一段解释性视频。第一个周期后三个月,我们又进行了两个回顾性周期.结果共分析96例患者的手术记录。干预之后,注意到有关日期的文档显着改善;遵循的程序;以及外科医生的详细信息,助手们,麻醉师,切口,手术类型,手术诊断,并发症,额外的程序,组织细节,涉及到假肢,闭合技术,术后计划,和外科医生的签名。我们还观察到EVOLVE系统中操作笔记的上传显着增加。结论经过员工教育后,手术笔记的质量大大提高。海报展示,和手术室中的扫描仪安装。重要的是要有一个有效和结构良好的计划,以改善操作记录的过程,从而最终提高整体患者护理。
Background and objective Missing information or mistakes in patients\' medical records, including those related to intraoperative and postoperative information, in an operative note can have profound clinical, ethical, and medicolegal implications. Operative notes should be informative, clear, and inclusive of the necessary data and should be collated immediately following surgery. In this study, we aimed to determine the ways to improve the quality of operative notes in the field of vascular surgery. Methods In this retrospective analysis, we compared the operative notes of 32 patients in the Department of Vascular and Endovascular Surgery, University Hospital Galway, against the standard set by the Royal College of Surgeons in Ireland (RCSI) (Code of Practice for Surgeons RCSI, 2018) and presented the results to our departmental staff. To facilitate an improvement in the quality of operative notes, a structured poster checklist was designed and displayed in the operating theatre. Furthermore, a scanner was set up in the operating theatre with clear and easy-to-follow instructions for uploading the operative notes into our hospital\'s online and digital patient record system (EVOLVE). An explanatory video was circulated among the staff. Three months after the first cycle, two further retrospective cycles were performed. Results A total of 96 patients\' operative notes were analysed. Following the intervention, a significant improvement in documentation was noted concerning the dates; procedures followed; as well as the details of surgeons, assistants, anesthetists, incisions, surgery types, operative diagnoses, complications, additional procedures, tissue details, prostheses involved, closure techniques, postoperative plans, and surgeons\' signatures. We also observed a significant increase in the uploading of the operative notes in the EVOLVE system. Conclusions The quality of the operative notes improved considerably after staff education, poster display, and scanner installment in the operating theatre. It is important to have an efficient and well-structured plan to improve the process of operative note-keeping, thereby ultimately enhancing overall patient care.