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.

  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.