Muhammad Danish Muneeb, Mirza Agha Naushad Baig, Muhammad Kamran, Shafaatullah Qudratullah, Muhammad Saddique Arain
{"title":"评估普外科手术记录的质量和标准;巴基斯坦一所教学机构的经验。","authors":"Muhammad Danish Muneeb, Mirza Agha Naushad Baig, Muhammad Kamran, Shafaatullah Qudratullah, Muhammad Saddique Arain","doi":"10.12669/pjms.40.8.9443","DOIUrl":null,"url":null,"abstract":"<p><strong>Objective: </strong>To evaluate the quality and standard of hand-written operative notes in a teaching institute.</p><p><strong>Methods: </strong>This prospective study was carried out in the department of surgery, Fatima Hospital, Baqai Medical University, from January 2023 till May 2023. One hundred fifty operative notes from general surgery domain were considered. These notes were evaluated according to the guidelines of Royal College of Surgeons, with added-on a few variables by the author.</p><p><strong>Results: </strong>All 150 notes were handwritten. Resident surgeon wrote the operative notes under the supervision of primary surgeon. There was a deficiency in mentioning medical record number, procedure starting time and duration of surgery. An important statement about the hemostasis is that it is secured-per-operatively was not documented. The residents were reluctant to explain the surgical procedures diagrammatically. The operative room number was missing in all notes. Post operative instructions lacked the information for nothing per oral, blood pressure, temperature, pulse rate, and input and output charting.</p><p><strong>Conclusion: </strong>It is observed that the operative surgical notes were however explainable about the procedure, but quality and standard was not matchable with that of Royal College of Surgeons notes. Hence, a lack of formal training for the resident surgeons in operative notes writing was observed. This study is a thought provoker to the surgeons and a guide to resident trainees, and hospital management to provide a handful operative notes writing theme in the form of performa provided in the department.</p>","PeriodicalId":19958,"journal":{"name":"Pakistan Journal of Medical Sciences","volume":null,"pages":null},"PeriodicalIF":1.2000,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11395379/pdf/","citationCount":"0","resultStr":"{\"title\":\"Assessing the quality and standards of operative notes in general surgery; A teaching institute's experience in Pakistan.\",\"authors\":\"Muhammad Danish Muneeb, Mirza Agha Naushad Baig, Muhammad Kamran, Shafaatullah Qudratullah, Muhammad Saddique Arain\",\"doi\":\"10.12669/pjms.40.8.9443\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p><strong>Objective: </strong>To evaluate the quality and standard of hand-written operative notes in a teaching institute.</p><p><strong>Methods: </strong>This prospective study was carried out in the department of surgery, Fatima Hospital, Baqai Medical University, from January 2023 till May 2023. One hundred fifty operative notes from general surgery domain were considered. These notes were evaluated according to the guidelines of Royal College of Surgeons, with added-on a few variables by the author.</p><p><strong>Results: </strong>All 150 notes were handwritten. Resident surgeon wrote the operative notes under the supervision of primary surgeon. There was a deficiency in mentioning medical record number, procedure starting time and duration of surgery. An important statement about the hemostasis is that it is secured-per-operatively was not documented. The residents were reluctant to explain the surgical procedures diagrammatically. The operative room number was missing in all notes. Post operative instructions lacked the information for nothing per oral, blood pressure, temperature, pulse rate, and input and output charting.</p><p><strong>Conclusion: </strong>It is observed that the operative surgical notes were however explainable about the procedure, but quality and standard was not matchable with that of Royal College of Surgeons notes. Hence, a lack of formal training for the resident surgeons in operative notes writing was observed. This study is a thought provoker to the surgeons and a guide to resident trainees, and hospital management to provide a handful operative notes writing theme in the form of performa provided in the department.</p>\",\"PeriodicalId\":19958,\"journal\":{\"name\":\"Pakistan Journal of Medical Sciences\",\"volume\":null,\"pages\":null},\"PeriodicalIF\":1.2000,\"publicationDate\":\"2024-09-01\",\"publicationTypes\":\"Journal Article\",\"fieldsOfStudy\":null,\"isOpenAccess\":false,\"openAccessPdf\":\"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11395379/pdf/\",\"citationCount\":\"0\",\"resultStr\":null,\"platform\":\"Semanticscholar\",\"paperid\":null,\"PeriodicalName\":\"Pakistan Journal of Medical Sciences\",\"FirstCategoryId\":\"3\",\"ListUrlMain\":\"https://doi.org/10.12669/pjms.40.8.9443\",\"RegionNum\":4,\"RegionCategory\":\"医学\",\"ArticlePicture\":[],\"TitleCN\":null,\"AbstractTextCN\":null,\"PMCID\":null,\"EPubDate\":\"\",\"PubModel\":\"\",\"JCR\":\"Q2\",\"JCRName\":\"MEDICINE, GENERAL & INTERNAL\",\"Score\":null,\"Total\":0}","platform":"Semanticscholar","paperid":null,"PeriodicalName":"Pakistan Journal of Medical Sciences","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.12669/pjms.40.8.9443","RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q2","JCRName":"MEDICINE, GENERAL & INTERNAL","Score":null,"Total":0}
Assessing the quality and standards of operative notes in general surgery; A teaching institute's experience in Pakistan.
Objective: To evaluate the quality and standard of hand-written operative notes in a teaching institute.
Methods: This prospective study was carried out in the department of surgery, Fatima Hospital, Baqai Medical University, from January 2023 till May 2023. One hundred fifty operative notes from general surgery domain were considered. These notes were evaluated according to the guidelines of Royal College of Surgeons, with added-on a few variables by the author.
Results: All 150 notes were handwritten. Resident surgeon wrote the operative notes under the supervision of primary surgeon. There was a deficiency in mentioning medical record number, procedure starting time and duration of surgery. An important statement about the hemostasis is that it is secured-per-operatively was not documented. The residents were reluctant to explain the surgical procedures diagrammatically. The operative room number was missing in all notes. Post operative instructions lacked the information for nothing per oral, blood pressure, temperature, pulse rate, and input and output charting.
Conclusion: It is observed that the operative surgical notes were however explainable about the procedure, but quality and standard was not matchable with that of Royal College of Surgeons notes. Hence, a lack of formal training for the resident surgeons in operative notes writing was observed. This study is a thought provoker to the surgeons and a guide to resident trainees, and hospital management to provide a handful operative notes writing theme in the form of performa provided in the department.
期刊介绍:
It is a peer reviewed medical journal published regularly since 1984. It was previously known as quarterly "SPECIALIST" till December 31st 1999. It publishes original research articles, review articles, current practices, short communications & case reports. It attracts manuscripts not only from within Pakistan but also from over fifty countries from abroad.
Copies of PJMS are sent to all the import medical libraries all over Pakistan and overseas particularly in South East Asia and Asia Pacific besides WHO EMRO Region countries. Eminent members of the medical profession at home and abroad regularly contribute their write-ups, manuscripts in our publications. We pursue an independent editorial policy, which allows an opportunity to the healthcare professionals to express their views without any fear or favour. That is why many opinion makers among the medical and pharmaceutical profession use this publication to communicate their viewpoint.