|dc.description.abstract||Introduction: General Medical Council fully endorse good documentation as an essential part of Good Medical Practice. National Patient Safety Agency stated that communication problems contributed majorly in-Patient Safety Incidents. WHO-SSC was one of the tools developed to prevent documentation errors. Little was known about the adherence of perioperative documentation to recommended guidelines in Mulago hospital and Uganda.
Objective: To determine adherence to perioperative notes taking standards and its influence on adverse events in MNRH.
Method: This study involved both retrospective and prospective arms. Retrospective arm involved review of patients’ files randomly selected between June 2018 to December 2018. Prospective arm involved consecutive recruitment and follow up of documentation on patients’ files till discharge, from February 2019 till sample size was achieved. Data extraction tool was developed from WHO SSCs, RCSE, pretested, coded and used to collect data. Data entered in EPIDATA version 3.1 and exported to STATA version 14 for further management and analysis. Frequencies and percentages were used to summarize data for objectives 1 & 2. A bivariable logistic regression model was used to test for the association between occurrence of adverse events and percentage of completed documentation.
Results: A total of 358 patient files were studied. None of the files had complete documentation. Majority of files had completion ranging from 50 to 75% with an average of 50.5%. The frequently missed items were; Doctor signature (11.2%), anesthetic review (12.9%), date, time, and clinician’s name in every entry (21.8%), only used approved abbreviations (22.6%), drug and allergy history (26.3%), marital status (34.6%), occupation (40.2%). Intraoperative documentation was the most poorly performed. Completion of documentation was found to be associated with occurrence of adverse events OR (95%CI): 0.96(0.91-0.99), P value <0.05. Commonest adverse events found were; Death (3.4%), unplanned return to operating room (3.9%), surgical site infection (4.2%), spent more than 24hrs in A&E (17.3%), prolonged hospital stay of >10days (22.6%), missed medicine (37.5% of other adverse events).
Conclusion: None of the files had completed documentation, with intraoperative documentation being the most poorly performed. Also, any unit increase in the percentage completion of documentation on average reduces the chances of occurrence of adverse events by 4%.||en_US