Enhancing the Quality of Surgical Documentation Through the Surgical Tool for Auditing Records (STAR): Experience...

Background Effective record-keeping is crucial for safe surgical care worldwide. While structured tools for auditing records exist, evidence from low- and middle-income countries (LMICs) remains limited. This study was conducted to uphold the standard of surgical record-keeping in a tertiary care center in Sri Lanka using the Surgical Tool for Auditing Records (STAR). Methods This prospective, descriptive closed-loop audit included 92 patient records, 44 from Cycle 1 (April 1-14, 2024) and 48 from Cycle 2 (April 15-28, 2024). The evaluation was conducted using the STAR, which assesses documentation based on 50 criteria distributed across six key domains. Structured templates and educational sessions were utilized as interventions. Both audit cycle scores were compared to draw conclusions. Results The overall quality of surgical documentation improved significantly, with the mean STAR score rising from 67.34 ± 8.32 to 77.11 ± 7.17 (p < 0.001). Statistically significant improvements were noted across most domains except Consent and Anesthetic Records. Enhancements were observed across all evaluated domains, with the Subsequent Entries category showing the most notable progress (34.8%), while the Anesthetic Records demonstrated the smallest improvement (3.31%). The Discharge Summary section performed exceptionally well, attaining an average score of 94.44 ± 5.61; however, the diagnosis was recorded in only 50% of the reviewed records (n = 24/48). Although the Consent domain improved by 25.89%, it continued to be the lowest-scoring area overall. Conclusion Simple, low-cost interventions, such as templates and structured feedback, significantly improved record-keeping quality. Although the STAR has been widely applied globally, this study adds valuable evidence from a Sri Lankan tertiary hospital, offering practical insights for enhancing surgical documentation in LMICs and other resource-limited healthcare systems.