The Value of Auditing Surgical Records in a Tertiary Hospital Setting

Assessing and improving quality of care should be of paramount importance to health care systems and providers. This study aimed to evaluate the quality of surgical records at the Jordan University Hospital.

We used the previously validated Surgical Tool for Auditing Records (STAR) to retrospectively evaluate the quality of surgical records of patients who underwent surgery in the general surgery department from 2016 to 2021. Total STAR and section-specific STAR scores were compared using the two independent sample Student's ttest on SPSS Statistics, version 23 (IBM Corp, Armonk, NY).

A total of 488 records were selected and evaluated using the STAR. The total STAR scores significantly improved steadily throughout the years compared to the baseline in 2016, reaching the highest in 2021. All domains had improved compared to the baseline except for anesthesia records that did not change from an already high baseline. The highest improvements between STAR domains were observed in Initial Clerking and Consent domains.

Our study demonstrates that significant improvements in the quality of surgical records can be achieved by simply using an electronic record entry system, personnel education, and systematic auditing.