DOI: 10.1093/bjs/znad241.502 ISSN:

491 Quality of Operation notes - Fit for purpose?

Narayanan Vinodkumar, Dylan Amin, John Rajasingh, Abdu Opaluwa, Ahmed Abdelwahed, Abhay Sharma
  • Surgery

Abstract

Aims

Every doctor should maintain accurate and contemporaneous records. Operation notes with accurate documentation are crucial for providing good medical care. This responsibility lies with the primary surgeon. The aim was to assess the quality of operation notes in accordance with standards by RCS guidelines ‘Good surgical Practice.’

Methods

120 General Surgery operation notes (Electronic and handwritten) were randomly identified over a period of 2½ months. This covered both elective and emergency operations. Reviewers collected the data from the operation notes and the analysis was completed by clinicians. The parameters that were evaluated were Name, Hospital number, Date, Time of the operation, Elective/Emergency, Procedure, Name of the surgeon, Assistant, Anaesthetist, Incision, Operative diagnosis, Findings, Complications, Details of tissue removed, Additional procedures, Name/serial number of prostheses, DVT prophylaxis, Antibiotics, Blood loss, Details of closure/suture material, Post-op instructions and signature.

Results

Of the above parameters, 6 met a standard of 100%, 7 a standard of ≥ 90%, 7 a standard of 50-89% and 2 achieved a standard of < 50%.

Conclusions

There are certain parameters that need improvement to achieve a standard of 100%. Actions have been taken to raise awareness of the essential requirements of operation notes, to facilitate compliance to the guidelines as well as reminders to ensure adherence to the process. This will further improve the quality of the operation notes. A re-audit subsequent to these above measures will furnish us with more information.

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