The Value of Auditing Surgical Records in a Tertiary Hospital Setting

Al–Qudah, Mahmoud A.; Aloqaily, Mohammed; Rabadi, Alexander; Nimer, Abdullah; Hafez, Sufian Abdel; Almomani, Amro; Alkhlaifat, Nizar S; Aldurgham, Ahmad; Fraij, Zeyad; Aloqaily, Wafi; Abedelrahman, Laith Bani; AlShati, Aya; Jabaiti, Samir; Hani, Amjad Bani; Abeeleh, Mahmoud Abu

doi:10.7759/cureus.21066

Cited by 5 publications

(3 citation statements)

References 35 publications

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“…The quality of surgical notes has significant economic and medicolegal effects in addition to its intrinsic medical implications. Additionally, properly documented records can be helpful for research advancement and auditing, which can enhance patient care delivery [ 21 ]. We have observed that the referral from where the patient came from was left out of the documentation.…”

Section: Discussionmentioning

confidence: 99%

“…Other methodologies like e-CRABEL and The Surgical Tool for Auditing Records (STAR) are modified versions of the CRABEL system that are more tailored to surgical records auditing and have been used in other studies with promising improvements [ 21 , 22 ]. Surgical Hospital Audit of Record Keeping (SHARK) is a new audit and teaching tool for junior doctors based on the Royal College of Surgeons guidelines to anonymously score the different surgical teams' medical records within a hospital [ 23 ].…”

Section: Discussionmentioning

confidence: 99%

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CRABEL Score Assessment for Oral Surgery Excision Biopsy Case Notes of Oral Squamous Cell Carcinoma

Aarthi,

Ramalingam,

Ramani

et al. 2024

Cureus

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Background Oral surgical records contain all the information regarding a patient, including their history, clinical findings, diagnostic test results, pre-and postoperative care, progress, and medication. Notes that are properly drafted will help the physician argue that the course of therapy is appropriate. Several tools have been created for auditing clinical records; one such tool that may be used for any inpatient specialty is the CRABEL score system developed by CRAwford-BEresford-Lafferty. Aims This research aimed to evaluate the oral surgical records using the CRABEL scoring system for quality assessment. Materials and methods The case audit was performed from June 2023 to February 2024 for all Excisional biopsy cases of Oral Squamous Cell Carcinoma. Relevant data was retrieved from the Dental Information Archival Software (DIAS) of Saveetha Dental College and Hospitals, Chennai. It was evaluated by two independent oral pathologists trained in CRABEL scores. Two consecutive case records were evaluated. Fifty points were given for each case record. Scoring was given according to initial clerking (10 points), subsequent entries (30 points), consent (5 points), and discharge summary (5 points). The total score was calculated by subtracting the total deduction from 100 to give the final score. The mean scores of the case records were calculated. A descriptive statistical analysis was done with Statistical Package for Social Sciences (SPSS version 23.0; IBM Inc., Armonk, New York). Inter-observer agreement and reliability assessment were made using Kappa statistics. Results From the DIAS in that period, the data of 52 cases were retrieved and reviewed. There was no proof of a reference source in the audited records, and one deduction was made to the reference score in the initial clerking, and the effective score was 98 out of 100. The mean values of 52 case records were also 98 out of 100. The observed kappa score was 1.0. There was no inter-observer bias in the scoring criteria. Both observers also gave the same scoring. Conclusion Our study illustrates that oral surgery case records in our institution were found to be accurate, as they maintained 98% of the CRABEL score value. Frequent audit cycles will help in standardizing and maintaining the quality of oral surgery case records.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

CRABEL Score Assessment for Oral Surgery Excision Biopsy Case Notes of Oral Squamous Cell Carcinoma

Aarthi,

Ramalingam,

Ramani

et al. 2024

Cureus

View full text Add to dashboard Cite

show abstract

“…In developed nations, there exists a highly effective national audit and comparative audit services system [ 11 ]. Alqudah et al [ 12 ] investigated the quality of surgical audits in a tertiary hospital in Jordan. This study showed that all elements of surgical audits had improved from baseline and that electronic materials and better personnel education could achieve higher performance in the surgical department.…”

Section: Discussionmentioning

confidence: 99%

The Role of Clinical Audits in Advancing Quality and Safety in Healthcare Services: A Multiproject Analysis From a Jordanian Hospital

Abu-Jeyyab,

Al-Jafari,

El Din Moawad

et al. 2024

Cureus

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Introduction Clinical audits have become essential instruments for evaluating and improving the standard of patient care in healthcare services. While individual clinical audits focus on particular aspects of care, multiple clinical audits across various domains, specialties, or departments provide a more comprehensive understanding of clinical practice and encourage systemic improvements. Methodology This study employed a mixed-methods approach to review and assess various clinical audits and quality improvement initiatives conducted at Al-Karak Governmental Hospital in southern Jordan. The study aimed to identify obstacles and possibilities of conducting clinical audits and provide suggestions for enhancing audit procedures and results. Data were collected from both retrospective and prospective sources and analyzed using descriptive and inferential statistics. Results The study comprised 11 audits conducted in three medical departments, namely surgery, obstetrics and gynecology (OB/GYN), and pediatrics, with a total of 618 participants. The improvements in adherence to guidelines after the second loop of all the audits were significant and showed significant improvements in adherence to guidelines, demonstrating the efficacy of clinical audits in improving clinical practice and outcomes. Conclusions Clinical audits are essential for maintaining and improving quality and safety in healthcare services, particularly in developing nations where emergency obstetric care is lacking. Multiple clinical audits provide a comprehensive understanding of clinical practice and encourage systemic improvements. The findings of our study suggest that clinical audits can lead to significant improvements in adherence to guidelines and better clinical outcomes. Future research should focus on identifying best practices for conducting clinical audits and evaluating their long-term viability and expandability.

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Evaluation and Improvement of the Quality of Surgical Operative Notes in the Department of General Surgery at Dongola Teaching Hospital, Sudan

Elhadi Bakheet,

Muhammed,

Mohamed

et al. 2024

Cureus

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The Value of Auditing Surgical Records in a Tertiary Hospital Setting

Cited by 5 publications

References 35 publications

CRABEL Score Assessment for Oral Surgery Excision Biopsy Case Notes of Oral Squamous Cell Carcinoma

CRABEL Score Assessment for Oral Surgery Excision Biopsy Case Notes of Oral Squamous Cell Carcinoma

The Role of Clinical Audits in Advancing Quality and Safety in Healthcare Services: A Multiproject Analysis From a Jordanian Hospital

Evaluation and Improvement of the Quality of Surgical Operative Notes in the Department of General Surgery at Dongola Teaching Hospital, Sudan

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