DOI: http://dx.doi.org/10.18203/2349-2902.isj20200049

A prospective closed loop audit on the quality of the operative notes in a general surgical unit in a quaternary care centre

Mohamed Javid, Shanthi Ponnandai Swaminathan, Arun Victor Jebasingh, Manivannan Velayutham, Rajeswari Mani

Abstract


Background: Proper documentation of the surgery done in the form of operative notes is a very important aspect of surgical practice. The aim of this clinical audit was to identify the existing standard of the operative notes written in a general surgical unit in a quaternary care hospital; and to compare it with the recommendations given by Royal College of Surgeons, England (in Good Surgical Practice, 2014) and if needed, to improve the standard of practice.

Methods: In the first loop of this prospective audit, 75 consecutive operative notes which were written were compared with the RCS guidelines and the areas which had missing data were identified. These areas were informed to the residents, who are primarily involved in the documentation of the operative notes. The second loop of the audit was conducted after a gap of 4 months involving 75 consecutive operative notes again.

Results: The areas which were initially deficient were better documented when analysed in the second loop.

Conclusions: Documentation of operative notes does not always comply with the set guidelines as highlighted in the first loop of our audit. But by employing a clinical audit it is possible to identify the existing deficiencies and thereby improving the standards of practice. Also, operative note writing should be taught as part of surgical training. Definitions should be clearly provided, and specific guidelines should be established to improve the quality of the operative notes and their use to improve patient safety.


Keywords


Clinical audit, Operative notes documentation, General surgical unit

Full Text:

PDF

References


Nyamulani N, Mulwafu W. The quality of hand-written operative notes in a surgical unit at Queen Elizabeth Central Hospital (QECH), Malawi: A prospective completed audit loop study. Malawi Medical J. 2018;30(2):86.

Rogers A, Bunting M, Atherstone A. The quality of operative notes at a general surgery unit. S Afr J 2008;98:726-8.

Hamza AA, Abdalrahim HM, Idris SA, Ahmed OM. Evaluating the operative notes of patients undergoing surgery at Omdurman teaching hospital, Sudan. Sch J App Med Sci. 2013;1(6):668-72.

Good Surgical Practice 2014. Royal College of Surgeons (England) Available at: http://www. rcseng.ac.uk/publications/docs/good-surgical-practice. Accessed on 3 November 2019.

Payne K, Jones K, Dickenson A. Improving the Standard of Operative Notes within an Oral and Maxillofacial Surgery Department, using an Operative Note Proforma. J Maxillofacial Oral Surg. 2011;10(3):203-8.

Bateman ND, Carney AS, Gibbin KP. An audit of the quality of notes in an otolaryngology unit. J Roy Coll Surg Edin. 1999;44:94-5.

Din R, Jenna D, Muddu BN. The use of an aide-memoire to improve the quality of operation notes in an orthopedic unit. Ann R Coll Surg Eng. 2001;83:319-20.

Hussainy HA, Ali F, Jones S, Mcgregor-Riley J, Sukumar S. Improving the standard of operation notes in orthopaedic and trauma surgery: the value of a proforma. Injury. 2004;35(11):1102-6.