Background: An accurate, complete, legible medical record implies accurate, complete organized assessment and management of the patient. Operation notes as one of the important patient's medical records are often produced as evidence in medico-legal cases. In a court of law, that which is not written down may be perceived as never having occurred. Poorly written and illegible notes, along with the use of confusing abbreviations, are a common source of weakness in a surgeon's defense. Objectives: This audit was carried out mainly to assess and review the compliance and adhere of surgeon to existing operation guidelines sheet of ministry of health (form 15), and to enhance professionalism. Methodology: In this retrospective audit, 266 operation notes were reviewed in general surgical department of King Faisal Hospital, Makkah, Kingdom of Saudi Arabia, during a period of six months (January -June 2007). Because we have no standing ethical committee in our hospital the approval and permission were given by the administration for this study. Notes were scrutinized and reviewed for the quality, accuracy of patient's personal data, details of operation and name of surgeon, operating team, details of operation, swabs, instruments counts, as well as for the inclusion of unacceptable abbreviations. The standard operation sheet (form 15) guideline of Ministry of Health, Kingdom of Saudi Arabia, attached to the patient's file was used as a reference. Results: None of the notes were completely filled in this audit, some of important vital data of patients e.g. identification data were missed in (122 patients 45.9 %), and usage of non standardized abbreviations was found in 118 (44.4%). The types of the operation (emergency/elective) was recorded in 179 (67.3%) of all the operative notes. The time of the operation was recorded in 129 (48.5%) of the operative notes. Wound closure details were recorded in 153 (57.5%) of the notes and many other data like name of surgeon, anesthesiologists, type of anesthesia were variably missed. Conclusion:We conclude that a simple compliance to the attached operation note sheets can significantly improve the quality of the notes, continuity of care and potentially avoid medico-legal problems. There is an urgent need for revision and modification of form No: 15 operation sheet of Ministry of Health as well as introduction of computer database in operation notes. This should be an issue for the Faculty of Medicine, making the training of future surgeons more effective.
Aims and objectives: In this article we aim to sharing and exchanging experiences at all levels of applying objective structured clinical examination (OSCE), to reduce trial and errors cost inefficiencies and to help and accelerate the acceptance the new comers to this assessment tool. Setting and Methods: The department of surgery, faculty of medicine, Umm-Alqura University Makkah adopting OSCE as an essential tool of assessment in fourth, fifth and sixth years, from the first batch of the students (1420H/1999/2000). It was first held in may 2000 (batch I-21 students) and the numbers gradually increasing, till it reached 146 students in 2007 (batch 7). During these seven years experience of running the examinations we have run till now more than twenty five consecutive OSCE examinations, and sometime quadruplicated, which have been continuously evaluated and reviewed with the help of our external examiners. We are always refining the process and content with some development of new and innovative implementation, the department has improved the process and contents of OSCE. Lessons learned and conclusions: A well-organized OSCE requires significant investment in terms of planning, resources and enthusiasm, but can have potentially beneficial impacts on the assessments tools especially in big number of candidates. However OSCE is a very good adjunct tool of assessment, and can be used in multicentric ways for big number of candidates, but also has its limitations and should be combined with other forms of assessment, which may be more valid and comprehensive to test competencies not easily tested within the OSCE format.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
customersupport@researchsolutions.com
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.