苏丹阿布哈马德医院战争期间操作笔记的审计,苏丹
Muhammad Omer1, Mohammed Elfatih Ahmed Yousif2, Almthani A Hamza3
1College of Medicine and Surgery, Karary University, Omdurman, SDN.
Cureus
|September 29, 2025
概括
实施标准化操作笔记模板和员工培训显著提高了苏丹战时医院的外科手术文档质量. 这种低成本的干预措施提高了记录保存,以获得更好的患者护理和审计.
科学领域:
- 外科手术 手术手术
- 改善医疗保健质量 改善医疗保健质量
- 医疗文件 医疗文件
背景情况:
- 操作笔记对于外科护理,审计和法律目的至关重要,英国皇家外科医生学院等机构制定了标准.
- 由于人员短缺和缺乏标准化模板,受冲突影响的低资源环境中文档质量差很普遍.
- 这次审计涉及苏丹战争期间阿布哈马德医院的操作笔记质量.
研究的目的:
- 在战时环境中评估作战笔记的质量.
- 实施纠正措施以改善文档.
- 评估干预措施对操作性质量的影响.
主要方法:
- 从2024年8月到11月进行了两轮闭环审计.
- 第一个周期审查了28个回顾性笔记与19英格兰皇家外科医生学院的标准.
- 干预包括一个标准化模板,员工培训和视觉提醒,随后是对33个笔记的前性审计.
主要成果:
- 最初的审计发现了重大缺陷,其中不到35%的关键人员记录,只有3.5%的组织/假肢细节或抗生素预防记录.
- 干预后,关闭技术的文档改进到75.8%,外科医生的名称和诊断到75.8%,DVT预防到24.2%.
- 总体而言,合规性增加了28.2%,从24.1%上升到52.3%.
结论:
- 结构化的文档工具和专注的培训有效地改善了在充满挑战的战时环境中操作笔记的质量.
- 这些发现支持在资源有限的环境中使用低成本,高影响的质量改进方法.
- 标准化,持续培训和定期审计对于保持文档质量至关重要,特别是在不稳定的地区.
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