Current trends on clinical audit on surgical record keeping.

Abstract

The aim of this audit was to evaluate compliance with the local surgical record-keeping policy, identify areas of non-compliance and recommend improvements. A retrospective review was conducted using 30 randomly selected inpatient records from the surgical department, audited over two quarters (Q1 and Q2 of 2023). Data were extracted via the Electronic Data Management System (EDMS) and analyzed using the trust's record-keeping audit tool. The audit assessed compliance with 30 standards, with 10 standards targeting 100% compliance and 20 standards targeting 75% compliance. The audit highlighted significant deficits in surgical record keeping, with major issues being illegible entries, missing clinician designations and inconsistent use of approved abbreviations. Although improvements were observed in certain areas, such as proper documentation of date and time, further efforts are needed to enhance compliance across all standards. Recommendations include improved induction training, standardized documentation layouts and prompt recording of clinical events.