Improving the Quality of Medical Documentation in Orthopedic Surgical Notes Using the Surgical Tool for Auditing Records (STAR) Score.

Aims Due to the significant value held by medical records in terms of influencing patient care and medico-legal cases, this study aimed to investigate the quality of surgical notes and their improvement through periodic auditing during a six-year period at a major tertiary hospital. Methodology This study retrospectively evaluated surgical records of patients undergoing elective orthopedic surgeries at Jordan University Hospital from 2016 to 2021 using the Surgical Tool for Auditing Records (STAR) validated questionnaire. This questionnaire is composed of six distinct sections aimed to quantify the quality of medical records and demonstrate their associated deficiencies. Pre- and post-audit STAR scores were analyzed using the two independent sample t-test on Statistical Package for Social Sciences (SPSS) version 23.0 (IBM Corp. Armonk, NY). Results A total of 454 records were randomly selected and evaluated using the STAR questionnaire. There was an overall significant trend of improvement in the quality of records in all evaluated years compared to the 2016 baseline. The most pronounced improvements were in the records of 2021 as compared to the 2016 baseline (97.4 ± 0.7 vs. 94.3 ± 1.6; p:<0.05), in which the Initial Clerking, Subsequent Entries, and Operative Record domains had the most significant magnitude of change. The Consent and Anesthesia domains plateaued over the study's period in terms of overall quality. The most improved STAR domain was the Discharge Summary domain, in which four subsections (follow-up, diagnosis, complications, and medications on discharge) had significant STAR score increases (all; p:<0.05). Conclusion Our study implies that simple measures, including personnel education and training and periodic auditing, are effective measures in increasing the quality of surgical records. High-quality medical records need to be sustained and continuously improved, as they contribute to better health care, promote research, and contribute to economic gains through cost-effective practices.

Rate of late radial artery occlusion following cardiac catheterization at Jordan University Hospital.

Background: A recanalizing-process might decrease the incidence of radial artery occlusion (RAO) at a late assessment postcatheterization opposed to an early assessment. In this study, we evaluated the rate of RAO at a late postcatheterization period. Materials & methods: A retrospective case-control design was adapted including 148 patients who underwent trans-radial cardiac catheterization 7 to 18 months ago. The primary outcome was to assess RAO at the mentioned period while the secondary outcomes were to assess risk factors and symptoms associated with occlusion. RAO was assessed by Doppler ultrasound. Result: Thirteen patients (8.8%) had RAO in a median follow-up time of 13 months. Hand disability as measured by QuickDash score was significantly associated with RAO. Conclusion: This study adds a new insight on late RAO after coronary catheterization in Jordan and the region. Our findings support an ischemic mechanism contributing to long-term hand dysfunction.

Lay abstract Background: Certain complications might arise after heart catheterization through the hand, a procedure during which a catheter (long thin tube) is inserted into a blood vessel in the hand and threaded through to your heart. Occlusion (closure and blockage) of the blood vessel of the used hand is a common side effect of the procedure, and can occur a long time after the procedure takes place. Some scientists think that more people have blockage of the blood vessels soon after the procedure, rather than later on, possibly due to reopening of the vessel with time. Materials & methods: In this study, we evaluated the percentage of occluded blood vessels in patients who underwent catheterization several months earlier. We examined the blood vessels used for catheterization and collected data from patients who had the procedure 7­18 months before the study. Result &conclusion: Thirteen patients (8.8%) had occlusion of their blood vessels which was associated with symptoms of pain and numbness. Our study further supports the idea that symptoms after catheterization could be related to decreased blood supply of the hand due to occlusion of the blood vessels used for the catheterization.