A Closed-Loop Clinical Audit of Surgical Documentation of Inpatient Records at a Tertiary Level Hospital in Egypt

Optimal record keeping is a very essential component in health care provision especially in the surgical setting. This study aimed to evaluate the quality of surgical records in wards of a surgical department at Alexandria Main University Hospital, Egypt.

We created a systematically designed checklist using standard hospital protocol and universal guidelines presented in the previously validated STAR and CRABEL auditing tools as a basis for Yes/No questions. This checklist was then used to prospectively evaluate the quality of surgical records of patients who underwent surgery in the surgical oncology department from July 2023 to October 2023. Total STAR and section-specific STAR scores were then calculated and compared statistically.

A total of 80 records were randomly selected and evaluated using the STAR questionnaire. All domains showed improvement compared to the baseline except for the discharge summary which did not change from an already relatively high baseline of 96±0.0. The highest improvements were observed in the anesthetic record and operative record domains which increased from 90.65±4.3 and 86.15±5.347 to 100±0.0 and 95.6±3.365, respectively.

Our study demonstrates that significant improvements in the quality of surgical records can be achieved by simply using preprepared templates, personnel education, and systematic auditing.