Rectification in Urological Operation Theatre Notes and Documentation at a Public Sector Hospital and Implementing the Changes: A Closed-Loop Audit Rectification of Urological OT Documentation
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Abstract
Background: Clinical audits are essential for ensuring high-quality healthcare delivery, especially in surgical settings. Operation theater notes in urological surgeries are crucial for patient safety, postoperative care, and medico-legal purposes. However, their quality is often suboptimal.
Objective: This study aimed to assess and improve the quality of urological operation theater notes through a closed-loop audit at a public sector hospital.
Methods: A two-cycle audit was conducted at Benazir Bhutto Hospital, Rawalpindi. The first cycle involved a retrospective review of 100 urological operation theater notes against predefined criteria, including patient identification, preoperative diagnosis, intraoperative findings, and postoperative instructions. Following this, interventions such as educational workshops, standardized templates, and a checklist system were implemented. A second audit cycle evaluated the impact of these interventions on documentation quality.
Results: In the first cycle, compliance rates were 95% for patient identification, 80% for preoperative diagnosis, 70% for intraoperative findings, and 75% for postoperative instructions. After interventions, the second cycle showed improved compliance rates of 100% for patient identification, 95% for preoperative diagnosis, 90% for intraoperative findings, and 90% for postoperative instructions.
Conclusion: The closed-loop audit significantly improved the quality of urological operation theater notes. Implementing educational sessions, standardized templates, and checklists effectively enhanced documentation, underscoring the importance of structured approaches in healthcare quality improvement.
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