Abstract
Background: 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.Methods: 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).Results: 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.Conclusion: 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.
Highlights
Quality of care is a complex concept influenced by an elusive number of factors, some of which are easy to define and measure, while others are more abstract and socially constructed in nature [1]
While the traditional paper-based medical records are still widely used, electronic medical records (EMRs) have been increasingly incorporated in many facilities around the world, and shown to improve the quality of care compared to their paper-based counterpart [8,9]
Using 2016 as a baseline, total Surgical Tool for Auditing Records (STAR) scores of records of the later years kept improving significantly at a continuous pace along the years where the greatest increase was between years 2019 and 2020 with an unprecedented all-time high total STAR score in 2021 compared to previous years (Figure 1)
Summary
Quality of care is a complex concept influenced by an elusive number of factors, some of which are easy to define and measure, while others are more abstract and socially constructed in nature [1]. Cost-effective, high-quality care to patients is a core objective all medical institutions strive to accomplish. All efforts directed towards assessing and improving quality of care should be of paramount importance to health care systems and providers. One way to measure the quality of care provided to patients is by assessing the documentation quality of their medical information [2,3]. High-quality documentation should be comprehensive yet efficient focusing on presenting valuable information without becoming a barrier to proper care by wasting time and resources [4]. Medical records are an integral part of the health care system; they form the basic grounds for patients’ management, provide substantial data for medical research and protect medical professionals from legal liability [5,6,7]. 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
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