Audit of Operation Notes in an Orthopaedic Unit

Abstract

Purpose. To audit operation notes of 50 patients according to the guidelines of the Royal College of Surgeons. Methods. Proforma operation notes of 50 consecutive patients treated in an orthopaedic department were audited by a single reviewer, according to the guidelines of the Royal College of Surgeons in terms of date and time of surgery, name of surgeon, procedure, operative diagnosis, incision details, signature, closure details, tourniquet time, postoperative instructions, complications, prosthesis used, and serial numbers. Results. There were 45 trauma cases and 5 elective cases. The operating surgeons were consultants (32%), senior registrars (36%), and registrars (32%). 28% and 72% of the operation notes were written by operating surgeons and assistants, respectively. Of the 14 operating surgeons who wrote their own notes, one was a consultant, 6 were senior registrars, and 7 were registrars representing 6%, 33%, and 2014;22(2):218-20 44% of the respective grades of surgeons. All the notes were handwritten; 20% had illegible parts (all in the description of the operative technique). Documentation was good for date and time of surgery (100%), name of surgeon (100%), procedure (100%), duration of surgery (94%), operative diagnosis (92%), incision details (84%), and signature (84%). Documentation was poor for tourniquet time (32%; pneumatic tourniquet was used in 25 patients, only 8 of whom were documented), closure details (16%), and postoperative instructions (24%). Conclusion. Documentation of operative details in our department was generally good, except for closure details, tourniquet time, and postoperative instructions. Journal of Orthopaedic Surgery

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

“…A study by Sweed, et al, in their orthopaedic department, demonstrated similar deficient areas in their operation note documentation, particularly the documentation of tourniquet time [3]. The addition of a heading for tourniquet time in the typed notes has shown a noticeable improvement in documenting this particular area.…”

“…The revised guidelines in 2014 added in a proviso that all notes should ‘preferably be typed’. Up to 20% of handwritten orthopaedic operation notes have been shown to contain illegible parts [3]. Typed notes are beneficial in that they remove the issue of illegibility.…”

“…Several studies have audited orthopaedic operation notes to assess the quality of documentation using the British Orthopaedic Association guidelines [7,9] and using the 2008 Good Surgical practice guidelines [3,10]. This is the first study, to our knowledge, assessing the quality of documentation using the updated 2014 guidelines.…”

Audit of Orthopaedic Surgical Documentation

“…This is difficult to achieve with handwritten notes, especially in the context of legibility. Sweed et al found that 20 percent of their orthopaedic operation notes contained illegible parts [ 4 ]. The new 2104 guidelines now suggest that all notes should “preferably” be “typed.”…”

“…Our study examined our operation notes based on the recommendations found in the Royal College of Surgeons of England Good Surgical Practice Guide (2008) [ 2 ]. Only 1 previous study has used these same guidelines to audit its orthopaedic operation notes [ 4 ].…”