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BMC Oral Health
BMC Oral Health
BMC Oral Health
1472-6831
BioMed Central London

39261854
4811
10.1186/s12903-024-04811-8
Research
Assessment of the quality of oral squamous cell carcinoma clinical records in oral surgery with Surgical Tool for Auditing Records (STAR) scoring
Kakada Pravallika 1
http://orcid.org/0000-0003-1921-8336
Ramalingam Karthikeyan karthikeyanr.sdc@saveetha.com

1
Ramani Pratibha 1
Krishnan Murugesan 2
1 grid.412431.1 0000 0004 0444 045X Oral Pathology and Microbiology, Saveetha Institute of Medical and Technical Sciences, Saveetha Dental College and Hospitals, Saveetha University, Chennai, India
2 grid.412431.1 0000 0004 0444 045X Oral and Maxillofacial Surgery, Saveetha Institute of Medical and Technical Sciences, Saveetha Dental College and Hospitals, Saveetha University, Chennai, India
11 9 2024
11 9 2024
2024
24 106020 3 2024
26 8 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Background

The Surgical Tool for Auditing Records scoring system [STAR] focuses on surgical record auditing with promising outcomes. It offers a structured approach to evaluating the quality of surgical notes.

Aims and objectives

This study aimed to assess the effectiveness of the STAR in evaluating oral surgical records and identifying areas for improvement in documentation practices.

Materials and methods

The data was obtained from the Dental Information Archival Software (DIAS) of our institution. The sample size was determined using G*Power 3.1.9.4 software. Fifty consecutive oral surgery clinical records of oral squamous cell carcinoma patients were evaluated using STAR. Each record was reviewed for adherence to documentation standards including Initial Assessment (10 points), Follow-up Entries (8 points), Consent Documentation (7 points), Anesthesia Report (7 points), Surgical Log (9 points), and Discharge Synopsis (9 points). compiling a total STAR score (50 points). The data was tabulated in Google Sheets. The descriptive statistics with inter-observer agreement and the mean score were recorded.

Results

We observed that each of the 50 records received a score of 49/50 points on the STAR. Deductions were necessary in the Operative record section due to the lack of information regarding the sutures used.

Conclusion

To summarize, this study emphasizes the effectiveness of the STAR scoring system in evaluating the quality of oral surgical records. Identifying deficiencies, particularly in documenting operative details, can improve the completeness and accuracy of patient records. It can ultimately enhance patient care and facilitate better communication among healthcare professionals.

Keywords

STAR scoring system
Patient record
Healthcare audit
Oral Surgical records
Documentation quality
Quality monitoring
issue-copyright-statement© BioMed Central Ltd., part of Springer Nature 2024
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pmcIntroduction

Comprehensive medical documentation was crucial for delivering quality healthcare, supporting communication, legal compliance, and research endeavors. Accurate records promote patient safety and informed decision-making, highlighting their essential role in healthcare delivery. The quality of ward rounds and documentation can impact patient outcomes [1]. Organizations must assess the quality of care they deliver to ascertain its safety, effectiveness, efficiency, accessibility, patient-centeredness, and equity, by the Institute of Medicine (IOM) [2] and the World Health Organization (WHO) [3]. Multiple authors have noted that inadequate information quality in clinical records could signal substandard care and may correlate with increased rates of adverse patient safety incidents. [4–8] This was especially evident regarding drug-related complications in which potential causes may include errors in medication prescription writing, involving unreadability or the omission of crucial details like the date of prescription, dosage amount, or method of administration [9].

It was required that regular assessments be conducted to evaluate performance against those standards. STAR [Surgical Tool for Auditing Records ] is a valuable and reliable tool, noted for its effectiveness and reproducibility. The Royal College of Surgeons [RCS] developed protocols for healthcare record maintenance, upon which the STAR was subsequently based [10]. This assessment comprehensively evaluates different components, including the Initial Clerking, Subsequent Entries, Consent Documentation, Anaesthetic Record, Operative Record, and Discharge Summary [11]. The tool has been validated and proven effective in assessing the quality of medical records across different specialties [12]. Its implementation can help healthcare organizations identify areas for improvement and enhance overall documentation practices.STAR provides a standardized approach to auditing clinical records, promoting consistency and reliability in record-keeping assessments [12]. STAR can facilitate communication among healthcare providers, support clinical decision-making, and improve patient care outcomes. The study aims to apply the STAR scoring system for assessing surgical records, illustrating its application and effectiveness in objectively evaluating the quality of documentation in the surgical setting. The research question is “How effective is the STAR (Surgical Tool for Auditing Records) scoring system in evaluating the quality of oral surgical records, and what areas need improvement in documentation practices?”

Methods

A pilot study was conducted to assess the note-keeping quality of excisional biopsy cases of Oral Squamous Cell Carcinoma patients. Ethical approval was granted by the Institutional Human Ethical Committee under reference number: IHEC/SDC/PhD/OPath-1954/19/TH-001.

The study design and sample size estimation using G*Power analysis software (Version 3.1.9.4, Kiel, Germany) was performed with an alpha level of 0.05 and a power of 0.90, referencing previous literature [15]. We also considered the minimum sample size of 28 determined by the prevalence rate and treatment rendered for Oral Squamous Cell Carcinoma cases in India [14] and the final sample size was set at 50. Two oral pathologists, trained in STAR scores, independently evaluated the data. Retrieved case records were evaluated utilizing the STAR scoring system. Oral surgery case records from September 2023 to February 2024 data were retrieved from Saveetha Dental College and Hospitals using Dental Information Archival Software (DIAS) in Chennai.

The notes were assessed following the procedures outlined in the original paper [12]. It was a comprehensive set of surgical notes consisting of 50 essential entries. (Fig. 1) These entries have been carefully chosen to align with established guidelines for medical note documentation. To ensure an accurate assessment of note-keeping quality throughout the document, the scoring system assigns weights to different sections. Admission carries a weight of 20%, subsequent entries 16%, consent 14%, anesthetic record 14%, operative record 18%, and discharge summary 18%. This weighted approach minimizes the potential for errors that may arise from varying section weights, providing a more precise reflection of note quality. Furthermore, dividing STAR into distinct sections enables subgroup analysis, facilitating targeted identification of deficiencies and areas for improvement. The design of the tool incorporates most of the guidance but excludes sections related to nursing care plans, postmortem examinations, and admissions to the intensive care unit, as they were considered separate components within case notes.

The scoring framework was structured to align with the recording of patient case details as previously outlined. Within each division, essential elements were further broken down to define what constitutes a complete entry. Deductions were made for each missing component, ensuring a comprehensive evaluation of documentation.

Initial clerking

This should serve as the primary entry by an individual within the surgical division. It must include the name of the patient positioned at the onset of the clerking area, the hospital identification number of the patient, origin of the referral, attending consultant, assessment date and time, preliminary diagnosis, requested tests and results, allergies, preliminary management strategy, name, position, and contact details of the individual making entry. Commencement deduction of points applies for any incomplete entry.

Subsequent entries

Four consecutive entries may be reviewed. It includes the name of the patient, the identification number should be in the extension section, along with the time and date of the entry, and title of the entry, appropriate comments on patient observations/general condition, relevant results, a management strategy, name, signature, bleep number, and post legible entries. In determining this subscore, divide the total deductions by the number of entries reviewed for consistent scoring.

Consent

It includes the name of the patient, hospital identification number, and date; performed surgeries; full site description; advantages of the proposed technique; potential hazards and adverse outcomes; signatures of both the patient and consenting physician; and the name, position, and contact information of the assenting physician.

Anesthetic record

This must include the anesthetist’s name; evaluation before surgery; medications and dosages given during anesthesia; availability of monitoring information; intravenous fluids administered during anesthesia; post-anesthesia guidelines; and the signature and name of the individual responsible for the entry.

Operative documentation

The deduction was made for every omitted entry, including the name of the patient, date of operation, hospital identification number; Surgical practitioner’s name; following the procedure diagnosis; operative findings description; extracted tissues details; details regarding stitching materials utilized; prosthetic devices with identification numbers [if applicable]; post-operative guidance; name of the surgeon and signature.

Discharge summary

Entries should include the name of the patient, hospital identification number and address; Dates of admission and discharge; diagnosis upon discharge; discharging consultant; relevant investigations and results; operations and procedures performed; presence or absence of complications; medications upon discharge; and follow-up details [12].

Scoring evaluation

To evaluate utilizing the STAR scoring system, 50 consecutive sequence cases were examined following discharge. Deductions apply for each entry that was not included, and upon completion, The overall count of deductions across the case note series was calculated. The STAR score was then determined utilizing the formula: 2,500 - cumulative deductions throughout the series / 10. The value 2,500 was derived by multiplying 50 (series of documentation) by 50 (Points allocated for each case)(Fig. 1).

Fig. 1 The pictorial representation of the STAR scoring sheet [12]

Assessment cycle

An audit was conducted using STAR, wherein 50 consecutive excisional biopsy case notes of Oral Squamous Cell Carcinoma patients discharged from September 2023 to February 2024, Oral surgery department, Saveetha Dental College and Hospital were examined. The data was retrieved from Dental Information Archival Software (DIAS), Saveetha Dental College and Hospitals in Chennai, Tamilnadu, India. All notes within the sample were evaluated by the same auditor. Scores and results were compiled, and analyzed for total score and potential shortcomings in note-keeping areas.

The interobserver agreement involves assessing the consistency of scoring among different observers. It ensures that the scoring process is accurate and reliable by comparing the evaluations.

Results

For this pilot assessment, The data were obtained from Dental Information Archival Software (DIAS) at Saveetha Dental College and Hospitals in Chennai. The audit focused on excisional biopsy cases recorded during that period, assessing them based on the STAR score. A review of case notes for 50 consecutive cases was conducted. The STAR score evaluation of the 50 case notes put together was 98%. Deductions were made in the Operative record section because suture details were missing, emphasizing the importance of comprehensive documentation Initial clerking was scored for 10 points, subsequent entries were scored for 8 points, consent was scored for 7 points, the anesthetic record was scored for 7 points, the operative record was scored for 9 points and discharge summary was scored for 9 points. Thus, the total STAR score was 50 points. The combined scores of 50 assessed records for each criterion are summarized [Table 1]. Initial clerking scored full points, Subsequent entries showed full points, Consent showed full points and the Anesthetic record showed full points. The operative record showed a deduction of 50 points comprising 88.8%.

Table 1 STAR score and reductions from each section with corresponding percentages of the given information, missing information, and the final STAR score

Field	Total score / maximum points (points x 50 records)	Percentage of Total given information	Total deductions / maximum points (points x 50 records)	Percentage of missing information	
Initial clerking (10 points)	500/500	100%	0/500	0%	
Subsequent entries (8 points)	400/400	100%	0/400	0%	
Consent (7 points)	350/350	100%	0/350	0%	
Anesthetic record (7 points)	350/350	100%	0/350	0%	
Operative record (9 points)	400/450	88.8%	50/450	0.12%	
Discharge summary (9 points)	450/450	100%	0/450	0%	
STAR SCORE (50 points)	[2450/2500 ] x 100	98%	[50/2500] x 100	2%	

In this study, it was observed that each surgical note received an identical score of 49 points, highlighting a remarkable consistency within the studied samples [Fig. 2]. Initial clerking criteria (20%), Subsequent entries (16%), Consent (14%), Anesthetic record (14%), Operative record (18%), and Discharge summary (18%) were the Standard STAR score. The results of this study showed Initial clerking criteria (20%), Subsequent entries (16%), Consent (14%), Anesthetic record (14%), Operative record (17%), and Discharge summary (18%).

Fig. 2 The graphical representation of STAR score - standard and STAR score- audit result

The results of the study revealed uniformity across all surgical notes, with each note receiving a score of 49 points on the STAR score. There were no scoring differences between the two observers. There was no inter-observer bias and the kappa score was 1.0.

Discussion

Global statistics indicate that oral and lip cancers hold the sixth position in terms of mortality, with a reported rate of 10.2% [14, 15]. Thorough documentation was essential, serving as the foundation for informed decision-making and in the pursuit of continuous enhancement of patient care and monitoring treatment outcomes [16, 17].

The STAR scoring system, designed to assess the quality of surgical notes, provides a comprehensive framework for evaluating documentation standards in healthcare settings [12, 13]. The guidelines for medical record-keeping were initially developed by the Royal College of Surgeons [RCS], serving as the foundation for the subsequent development of STAR [10]. This scoring system, consisting of 50 essential entries, allows for a thorough examination of note-keeping practices and ensures adherence to established guidelines.

In this study, the methodology involved assessing 50 consecutive sets of surgical notes utilizing the STAR proforma upon discharge. Each note was reviewed and scored based on the presence or absence of essential elements, such as patient identification, Follow-up Entries, Consent Documentation, Anaesthetic Records, Surgical Procedure Log, and Discharge reports [11].

The result indicated consistency among all surgical notes, with each achieving a score of 49 out of 50 points on the STAR scoring system. Deductions were applied in the Operative record section due to the absence of details regarding sutures used, indicating areas for improvement in documentation practices. This uniformity across the evaluated cases shows a significant adherence to documentation standards among the surgical team. The findings suggest that the practitioners consistently captured essential information and maintained a high level of accuracy and completeness in their documentation practices. This level of consistency was essential to guarantee the reliability and integrity of patient records, which were essential for delivering high-quality patient care and facilitating effective communication among healthcare professionals. The uniformity in scoring also reflects a systematic approach to note-keeping, underscoring the importance of standardized processes in healthcare settings to promote consistency and reliability in clinical documentation. Deductions were made in the Operative record section specifically for the absence of details regarding the sutures used. This deduction was applied due to the lack of information about this aspect within the noted entries which suggests a gap in the documentation of surgical procedures, highlighting the need for comprehensive recording of all pertinent details to ensure thoroughness and accuracy in patient records.

Various scoring systems have been developed and validated to quantify and standardize the auditing process, including the CRABEL (CRAwford – BEresford – Lafferty) scoring system [18, 19], SOAP (Subjective, Objective, Assessment, Planning) [20], SHARK (Surgical Hospital Audit of Record Keeping [21] and STAR(Surgical Tool for Auditing Records) scoring system which assigns numeric scores across different domains. Clinical record audits and their impact on overall quality improvement have been cited in recent literature [22–24].

Overall, these results emphasize the effectiveness of the documentation practices implemented in the study’s surgical setting, highlighting the dedication of healthcare professionals to maintaining thorough and accurate patient records [1]. The scoring criteria exhibit no inter-observer bias, ensuring consistency and objectivity in the assessment process. This feature enhances the reliability of the scoring system for evaluating surgical notes. The Maxillofacial Surgery Team of Surgeons, Nurses, and Postgraduate Residents were sensitized about the STAR scoring and missing information about missing suture details. They were educated and consistently reminded during weekly departmental meetings.

Clinical record audits are crucial for the maintenance of quality standards, regulatory compliance, and patient safety in healthcare settings. By systematically reviewing patient records, audits identify specific areas for improvement in treatment delivery, highlight areas that require training needs, and mitigate potential risks. Additionally, such audits provide valuable data for research and performance evaluation, supporting evidence-based practice and continuous enhancement of healthcare outcomes.

The limitation of our study is that we have applied STAR scoring only for excision cases of Oral Squamous Cell Carcinoma in our institution. Other available scoring systems like CRABEL, SOAP, and SHARP assess different parameters of the clinical records that were not included in our study. We are currently pursuing STAR scoring for other oral surgery records including trauma, oro-facial clefts, orthognathic surgery, and other procedures performed under general anesthesia.

Conclusion

In conclusion, our study demonstrated the effectiveness of the STAR scoring system in evaluating the quality of surgical notes The study demonstrated the effectiveness of the STAR scoring system in evaluating the quality of surgical notes. The implementation of STAR could assist in pinpointing areas for enhancement and improving overall documentation practices. While uniformity was observed across all notes, areas for improvement were identified, particularly in the documentation of operative details. Addressing these deficiencies will enhance the comprehensiveness and accuracy of patient records. It will improve patient care and communication among healthcare professionals resulting in a better quality of life.

Acknowledgements

We thank Dr. Deepak Nallaswamy, Director of Academics, Saveetha Institute of Medical and Technical Sciences for initiating digital records in our institution that has enabled data search for this study.

Author contributions

Pravallika Kakada, Karthikeyan Ramalingam, Krishnan Murugesan and Pratibha Ramani have made substantial contributions to the conception and design of the work, the acquisition, analysis, and interpretation of data; have drafted the work or substantively revised it.Pravallika Kakada, Karthikeyan Ramalingam, Krishnan Murugesan and Pratibha Ramani have approved the submitted version (and any substantially modified version that involves the author’s contribution to the study); Pravallika Kakada, Karthikeyan Ramalingam, Krishnan Murugesan and Pratibha Ramani have agreed both to be personally accountable for the author’s own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.

Funding

No funding was received from any financially supporting body, and there was no associated grant number. No funder was involved in manuscript writing, editing approval, or decision to publish.

Data availability

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Declarations

Consent for publication

Not applicable to this manuscript.

Competing interests

The authors declare no competing interests.

Ethical approval

Ethical approval was granted by the Institutional Human Ethical Committee under reference number: IHEC/SDC/PhD/OPath-1954/19/TH-001.

Informed patient consent

All patients’ clinical records were obtained with informed consent.

Clinical trial registration details

Not Applicable. It is only an observation of clinical records. This study did not use any clinical intervention or treatment procedures on patients.

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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