Design of an Electronic Site-Marking Form to Improve Completeness of Surgical-Site Documentation

Patient safety during surgical procedures requires accurate and well-documented verification of patient identity, the type of procedure, and the operative site and side. Manual site-marking forms may result in incomplete fields, omitted verifier signatures, documents that are difficult to trace, and limited monitoring of documentation completeness. This study aimed to design a web-based electronic site-marking form to support the completeness of surgical-site marking documentation. The study employed a Research and Development (R&D) approach, with system development using the Rapid Application Development (RAD) method. Data were collected through observation of the manual form and interviews with one operating-room manager, two surgical nurses, and one medical-record officer. The developed product included user authentication, data management, procedure and operative-site input, mandatory-field validation, and electronic signatures. Black-box testing showed that all tested features functioned in accordance with the specified requirements. The electronic form was designed to address problems found in the manual workflow through centralized storage, role-based access, validation, electronic verification, and an audit trail. Further research should conduct pre- and post-implementation evaluation, refine the anatomical visualization, assess usability and user acceptance, and test integration with the hospital information system (SIMRS).