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.
