The future of audit in surgery
Over the years a number of attempts has been
made to develop an audit system which will acquire data as a part of everyday
activity. The advantage of this type of data acquisition is that we can derive
outcome data, etc., as a part of normal working practice rather than having
specifically to undertake audit projects. In order to achieve this it will be
necessary to ensure that a few basic rules are followed.
•
Standard proformas will need to be developed to allow consistent data
entry.
•
There will be obligatory fields that have to be completed on all
patients.
•
Specific data fields will need to be created that are disease or
speciality specific.
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Data validation will need to be undertaken to check correct data entry.
•
Education of both healthcare workers to understand the electronic records
and the general public to demonstrate confidentiality and accuracy of records
will be necessary.
•
The systems must be able to produce reports automatically for clinical
purposes and for audit.
Using
an electronic record does not eliminate the need to ‘think’ what audits to
undertake but facilitates the acquisition and storage of useful data. An
individual will still need to develop specific audit projects and apply the
accepted rules to undertake the study. If the systems are successful the
completeness
of data should be high; patients will be traceable and surgeons will have direct
and rapid access to understanding their own practice and how it affects their
patients.