An Audit of Operative Notes: Facts and Ways to Improve*

Lefter, Liviu P.; Walker, Stuart; Dewhurst, Fleur; Turner, Richard

doi:10.1111/j.1445-2197.2008.04654.x

Cited by 67 publications

(57 citation statements)

References 3 publications

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“…The incidence of litigation in trauma and orthopaedics is on the rise [4]. Illegible notes can have a major impact on any surgeon’s defence in medico-legal cases [5]. Typed notes afford a clear and concise operation note which can be interpreted accurately by a large number of people.…”

Section: Introductionmentioning

confidence: 99%

Improving the Standard of Orthopaedic Operation Documentation Using Typed Proforma Operation Notes: A Completed Audit Loop

Coughlan

Ellanti

Moriarty

et al. 2017

Cureus

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IntroductionThe Royal College of Surgeons (RCS) published Good Surgical Practice guidelines in 2008 and revised them in 2014. They outline the basic standard that all surgical operation notes should meet.ObjectivesTo retrospectively audit 57 typed orthopaedic operation notes from St. James’s Hospital in Dublin (from August to November 2015) against the RCS Good Surgical Practice guidelines published in 2014. They were then compared with the department’s previous audit of handwritten notes to complete the audit loop.Materials and methodsA total of 57 orthopaedic operation notes were audited by a single reviewer. They were prospectively collected between August and November 2015. All notes were typed on the standard St. James’s Hospital operation note proforma.ResultsOf the surgeries, 89.5% were emergencies with 77.2% of them being performed by trainees. All of the operation notes were typed and signed by trainees. The procedure name, incision and closure details, tourniquet time (when relevant), and postoperative instructions were documented in 100% of the notes. In total, 80.7% had an operative diagnosis included while only 26.9% of the documentation had prosthesis serial numbers. All of the typed notes were deemed to be legible.ConclusionThe use of printed operation notes allows for improved legibility when compared to typed notes. Documentation standards remained very high in the same areas as the handwritten notes and a marked improvement was seen in areas that had been poorly documented.

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Section: Introductionmentioning

confidence: 99%

Improving the Standard of Orthopaedic Operation Documentation Using Typed Proforma Operation Notes: A Completed Audit Loop

Coughlan

Ellanti

Moriarty

et al. 2017

Cureus

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“…These include an aide-memoire attached to the operation sheet, poster/ checklist in the operation theatre, or the use of an operative note proforma sheet (handwritten/computerized) [3,6,7]. The use of a proforma alerts the user to fill all the specified criteria with a resultant improvement in compliance to guidelines.…”

Section: Discussionmentioning

confidence: 99%

Improving the Quality of Oral and Maxillofacial Surgical Notes in an Indian Public Sector Hospital in Accordance with the Royal College of Surgeons Guidelines: A Completed Audit Loop Study

Krishnan

Prasad

Madhan

2015

J. Maxillofac. Oral Surg.

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Aim Proper and adequate documentation in operation notes is a basic tool of clinical practice with medical and legal implications. An audit was done to ascertain if oral and maxillofacial surgery operative notes in an Indian public sector hospital adhered to the guidelines published by the Royal College of Surgeons England. Methods Fifty randomly selected operative notes were evaluated against the guidelines by RCS England with regards to the essential generic components of an operation note. Additional criteria relevant to oral and Maxillofacial Surgery were also evaluated. Changes were introduced in the form of Oral and Maxillofacial Surgery specific consent forms, diagram sheets and a computerized operation note proforma containing all essential and additional criteria along with prefilled template of operative findings. Reaudit of 50 randomly selected operation notes was performed after a 6 month period. Results In the 1st audit cycle, excellent documentation ranging from 94 to 100 % was seen in 9 essential criteria. Unsatisfactory documentation was observed in criteria like assistant name, date of surgery. Most consent forms contained abbreviations and some did not provide all details. Additional criteria specific to Oral and Maxillofacial Surgery scored poorly. In the 2nd Audit for loop completion, excellent documentation was seen in almost all essential and additional criteria. Mean percentage of data point inclusion improved from 84.6 to 98.4 % (0.001\ P value \0.005). The use of abbreviations was seen in only 6 notes. Conclusion Regular audits are now considered a mandatory quality improvement process that seeks to improve patient care and outcomes. To the best of our knowledge, this is the first completed audit on operation notes documentation in Oral and Maxillofacial Surgery from India. The introduction of a computerized operation note proforma showed excellent improvement in operation note documentation. Surgeons can follow the RCS guidelines to ensure standardization of operation notes.

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“…The extent of the problem was revealed in the results table [1,2,3]. Despite the fact that some operative notes were written by specialist, results showed that the problem was rampant.…”

Section: Discussionmentioning

confidence: 99%

“…According to the General Medical council (GMC),It is the doctors' duty 1,2 .Operation notes are useful in the management of patients post-operatively, surgical audit and research and an absolute necessity in medico-legal disputes. Lefter et al 3 emphasized the medico-legal importance, stating that patients have the right to have access to their medical records subject to certain conditions 3 . Teaching or training health facilities still remain the place for proper acquisition of skills in writing standard operation notes.…”

Section: Imentioning

confidence: 99%

Quality of Operation Notes in Niger-Delta University Teaching Hospital, Southern Nigeria

2013

IOSR-JDMS

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An Audit of Operative Notes: Facts and Ways to Improve*

Abstract: This audit suggests that handwritten surgical notes generate several errors that could lead to confusion when notes are reviewed for further follow up or are produced as evidence in medico-legal disputes.

Cited by 67 publications

References 3 publications

Improving the Standard of Orthopaedic Operation Documentation Using Typed Proforma Operation Notes: A Completed Audit Loop

Improving the Standard of Orthopaedic Operation Documentation Using Typed Proforma Operation Notes: A Completed Audit Loop

Improving the Quality of Oral and Maxillofacial Surgical Notes in an Indian Public Sector Hospital in Accordance with the Royal College of Surgeons Guidelines: A Completed Audit Loop Study

Quality of Operation Notes in Niger-Delta University Teaching Hospital, Southern Nigeria

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