ACTA SCIENTIFIC CLINICAL CASE REPORTS

Research Article Volume 5 Issue 5

Assessment of the Quality of Computerized Operation Notes at Yekatit 12 Hospital Medical College

Tolesa Chimdesa1, Wondwossen Amtataw1* and Trhas Tadesse2

1Department of Surgery, Yekatit 12 Hospital Medical College, Addis Ababa, Ethiopia
2Department of Public Health, Yekatit 12 Hospital Medical College, Addis Ababa, Ethiopia

*Corresponding Author: Wondwossen Amtataw, Department of Surgery, Yekatit 12 Hospital Medical College, Addis Ababa, Ethiopia.

Received: March 25, 2024; Published: April 19, 2024

Abstract

Background: Surgeons must maintain accurate, legible, and up-to-date records of patient information for optimal care and safety. However when use of computerized operation notes, posing initial challenges for surgeons until they adapt and the system matures. Addressing these challenges is crucial for improving caregiver practices and overall patient safety.

Objectives: To assess the quality of computerized operation in the department of general surgery.

Methods: A cross-sectional study design was utilized, and data entry and analysis were conducted using SPSS version 25. Chi-square tests were applied to selected parameters assumed to significantly impact patient safety.

Result: The entire computer auto generated elements such as time and date was 100% typed. Whereas some important element of the standard like the name of the anesthetist, scrub and circulating nurse, whether prophylactic antibiotics were given or not and the need for deep vein thrombosis prophylaxis were not typed at all. Overall the quality of operation note is poor and factors contributing to the poor adherence to the standard set by Royal College of surgeons’ guideline are the knowledge gap, the poor design of the system compared to the system.

Conclusion: There's a notable gap in the technical aspects of operations regarding standard elements. Urgent refinement of the system and teaching are needed to ensure better patient care continuity and meet operation note writing standards.

Keywords: Operation Notes; Medical Records; RSCE; Poor Quality

References

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Citation

Citation: Wondwossen Amtataw., et al. “Assessment of the Quality of Computerized Operation Notes at Yekatit 12 Hospital Medical College".Acta Scientific Clinical Case Reports 5.5 (2024): 21-25.

Copyright

Copyright: © 2024 Wondwossen Amtataw., et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.




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Acceptance rate32%
Acceptance to publication20-30 days
Impact Factor1.014

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