Diagnosis data, rather than documentation data, for surgical wound classifications provides a more accurate picture of surgical site infection rates, due to the discrepancies appearing in the wound classification information between diagnosis and documentation, according to an article published in the Journal of the American College of Surgeons.
Researchers analyzed one year of SSI data for pediatric patients who had received appendectomies at a single hospital, comparing hospital-documented surgical wound classifications with surgeons' postoperative wound diagnoses.
Of the more than 300 evaluated cases, more than nine in 10 showed discrepancies between information created by the surgeon and information documented by the circulating nurse. Surgeon diagnosis of wound severity was associated with increased SSIs, though circulating nurse-documented data was not.
The differences in the data can have a significant impact on outcome measures and quality reporting, which may contribute to incorrect analysis and perception of quality improvement efforts, according to the study.
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