A Clinical Audit of Operation Notes Documentation and the Impact of Introducing an Improved Proforma: An Audit Cycle

Hassan, Rao Erbaz; Akbar, Ismail; Khan, Arif Ullah; Hameed, Muhammad Bilal; Raza, Muhammad; Shah, Syed H; Shah, Syed H; Haroon, Hamza; Hanzala, Rao Aizaz

doi:10.7759/cureus.50281

Cited by 3 publications

(1 citation statement)

References 9 publications

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“…The significance of proformas in optimizing operation notes is well-established [7,8]. Despite having a wellstructured proforma for documenting operative notes in our hospital, the initial audit revealed deficiencies in 10 parameters outlined by the RCS guidelines.…”

Section: Discussionmentioning

confidence: 99%

Enhancing Documentation Precision in Ophthalmic Surgery: A Quality Improvement Project

Tanveer,

Khilji,

Gul

et al. 2023

Cureus

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Background Effective clinical documentation, particularly operative notes, is essential for maintaining healthcare standards and fostering interdisciplinary communication. This study focuses on improving the quality of ophthalmic operative notes by adopting the Royal College of Surgeons (RCS) guidelines for good surgical practice. Methodology A retrospective cross-sectional audit at Khyber Teaching Hospital, Pakistan, assessed 138 operative notes against the RCS criteria. After an educational session and the placement of memory aids in operation theaters, a re-audit of 125 notes was conducted. Parameters were selectively applied based on relevance to specific cases, and omissions were discussed with the local ethical committee. Results The initial audit revealed deficiencies in 10 critical areas, with only three parameters exceeding 85% accuracy. The re-audit showed significant improvement across these parameters, achieving documentation of 85.3% of all criteria. Paired t-test results indicated a substantial difference in documentation quality before and after interventions. Conclusions A combined strategy involving surgeon education, memory aids, and adherence to established standards significantly enhances operative note quality. The study underscores the importance of sustained reinforcement mechanisms for continuous improvements in documentation practices.

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Section: Discussionmentioning

confidence: 99%

Enhancing Documentation Precision in Ophthalmic Surgery: A Quality Improvement Project

Tanveer,

Khilji,

Gul

et al. 2023

Cureus

Self Cite

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Enhancing Surgical Operative Note Standards at Doka Hospital, Sudan: A Clinical Audit

Hassan Ibrahim,

Abdelrahman Zeineldeen,

Mohamed Mohamed Alameen

et al. 2024

Cureus

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Background Operating notes are crucial in surgical practice for post-operative care, future medical reference, and legal needs. They provide vital details about the procedure, guaranteeing patient safety and improving communication among medical staff. These notes include patient health status, surgical method, operation results, problems, and post-surgery plans. Established protocols for recording surgical operative notes are essential for medical education, research, and quality improvement efforts. The audit aimed to evaluate and enhance Doka Hospital's surgical operation notes, focusing on their quality, completeness, and potential areas for development. The audit aimed to apply necessary adjustments to raise standards and ensure high standards in medical treatment. Material and methods This retrospective-prospective study analyzed surgical postoperative notes from Doka Hospital's archives, following the implementation of a new format based on guidelines set by the Royal College of Surgeons of England. Staff training sessions were conducted to facilitate adoption. The audit population included surgical operative notes from the departments of general surgery and obstetrics and gynecology. The study collected 200 surgical operative notes, with 100 notes in the first cycle and 100 notes in the second cycle. Data was collected from the General Surgery and Obstetrics and Gynaecology departments using a predefined checklist, followed by analysis using the Microsoft Excel Sheets program (Microsoft Corporation, Redmond, USA). Ethical clearance was obtained from the ethical committee of Doka Hospital. The audit population consisted of 71 beds in a busy rural hospital with a majority of cases involving obstetrics and one-day surgical operations. Results Doka Hospital's surgical operative note review showed a significant improvement in documentation quality following a revised structure based on the Royal College of Surgeons of England's recommendations. Compliance with the criteria improved from 50.5% in the first cycle to 82.5% in the second cycle. Notable progress was made in date and time documentation, with a 96% increase in the second cycle. The proportion of anaesthetists' names also rose from 60% to 90%. The accuracy of recording surgical operation details increased from 87% to 94%. Documenting operational results, issues, and tissue removal also improved. Factors like the identity of the prosthesis or materials used remained unchanged in both cycles. Conclusion The introduction of a uniform style for recording surgical operational notes, together with focused training sessions, greatly improved the quality of surgical documentation at Doka Hospital.

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Screening for Deep Vein Thrombosis Using D-dimer Levels Based on Surgical Patients’ Characteristics

Kitamura,

Shiraishi,

Sakata

et al. 2024

Cureus

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A Clinical Audit of Operation Notes Documentation and the Impact of Introducing an Improved Proforma: An Audit Cycle

Cited by 3 publications

References 9 publications

Enhancing Documentation Precision in Ophthalmic Surgery: A Quality Improvement Project

Enhancing Documentation Precision in Ophthalmic Surgery: A Quality Improvement Project

Enhancing Surgical Operative Note Standards at Doka Hospital, Sudan: A Clinical Audit

Screening for Deep Vein Thrombosis Using D-dimer Levels Based on Surgical Patients’ Characteristics

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