Assessing the Quality of Urological Operation Notes in Accordance With the Royal College of Surgeons of England Guidelines: A Retrospective Cross-Sectional Study

Abstract

Objective This study aimed to assess the practices of documenting operative notes in the urology department at a tertiary care facility in Sudan. Materials and methods This cross-sectional, retrospective study evaluated the practices of documenting surgical notes for patients who required urological procedures at a tertiary hospital in Sudan. The study included all patients who underwent emergency or elective urological surgery between March 1, 2023, and April 1, 2023, under general or spinal anesthesia, regardless of age. The medical records were accessed to analyze the operative notes' standards. Sixty-two operative notes were included and analyzed. We used the Royal College of Surgeons of England (RCS) guidance as the standard for our study. The Royal College of Surgeons of England has provided comprehensive and standardized guidelines for writing an operative note, including patient identification, date and time of the procedure, type of procedure (elective/emergency procedure), name of surgeon and assistant, name of anesthetist, name of the procedure, type of incision, operative diagnosis, operative findings, complications encountered, any extra procedure performed with reason, details of tissue removed, added or altered details of closure technique, anticipated blood loss, prosthesis details, antibiotic prophylaxis, deep vein thrombosis prophylaxis, detailed post-op instructions, signature. Results A total of 62 consent forms were included. Patient identification, name of the surgeon and assistant, and name of the procedure were mentioned in 61 (98.4%). The operative diagnosis and details of tissue removed were written in 41 (66%). Antibiotic prophylaxis and deep vein thrombosis prophylaxis were given in 28 (45.2%) and 25 (40%), respectively. The type of anesthesia was mentioned in 56 (90.3%) of cases. The name of the anesthetist and anticipated blood loss: recorded completion rates of 12 (19.3%) and 18 (29%), respectively. The date and time of the procedure were completely documented in 59 (95.2%). Senior doctors wrote six (9.7%) of the operative notes with a completeness of four (66.7%). Junior doctors wrote 56 (90.3%) operative notes, and only 12 (21.4%) completed the essential components of the notes. Conclusions The current practices of documenting operating notes were shown to be imprecise. Handwritten operative notes do not follow standard practice. Using a pre-designed operating note that may be customized according to the circumstances of the operation is the preferred option. An educational session should be planned for junior doctors to focus on correct documentation and promote adherence to best clinical practices.