50 A Closed-Loop Clinical Audit on Surgical Documentation at a Tertiary Level Hospital in India: Where Do We Stand?

Abstract

Abstract Aim To perform an audit to check Quality & Compliance of Surgical documentation using STAR Score at a tertiary hospital in India. Method A total of 90 case files were studied and assessed in detail from all surgical departments. The audit was done for a period of 1 month at a tertiary hospital in India. The “STAR: Surgical tool for auditing records” tool was used to collect data accordingly. The results were then compared with standard guidelines and analyzed. A series of departmental training and implementation meetings were carried out. After 2 weeks, a re-audit was performed. Result The overall compliance score of the hospital was found to be 74%. Departments of General surgery and orthopedics showed a higher rate of compliance, each constituting 82% while the Department of Neurosurgery showed the least compliance of 62%. It was also seen that the maximum percentage of missing information consisted of anesthetic records and subsequent entries. After the re-audit, a considerable improvement was observed, with the compliance rate improving to 90% in all departments. Conclusion We believe that compliance and implementation of the STAR Score is mandatory, as it can significantly improve the quality of documentation and can be implemented universally.