Quality of operation notes in orthopaedic hip arthroplasty surgery: Are we complying with British Orthopaedic Association's guide to good practice?

Cu, Menakaya; Ingoe, Helen; Malhotra, Rishi; Shah, Maulik; Boddice, T.; Mohsen, Amr

doi:10.1177/175045891302301201

Cited by 3 publications

(3 citation statements)

References 3 publications

(1 reference statement)

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“…We achieved 92% compliance for documentation of a clear/detailed postoperative instruction and 90% for a clear follow-up plan following completion of our second cycle (from an initial 40% and 81% compliance, respectively, from the first cycle). An audit of hip arthroplasty operations by Menakaya et al (2013) led to 97% compliance with postoperative instructions [14]. These were the two areas (in addition to a clear venous thromboembolism [VTE] prophylaxis plan) that we felt impacted significantly on patient safety as junior doctors and nurses on the wards identified these as areas they struggled with.…”

Section: Discussionmentioning

confidence: 99%

A Closed-Loop Audit for Orthopedic Trauma Operation Notes Comparing Typed Electronic Notes With Handwritten Notes

Anazor¹,

Sibanda²,

Abubakar³

et al. 2022

Cureus

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IntroductionOperation notes are important documents for ensuring patient safety, effective communication between clinicians, and for medicolegal purposes. It is essential that they are clear and accurate. We audited the quality of our operation notes against the Royal College of Surgeons (RCS) of England's Good Surgical Practice Guidelines. MethodsThis was a prospective audit of 99 orthopedic trauma operation notes. In the first cycle, we audited 58 operation notes for orthopedic trauma surgical procedures. We audited 17 parameters per note. We presented our findings, implemented changes including the use of a typed operation note template, and performed a re-audit using 41 operation notes. ResultsOur documentation for 3/17 parameters was up to standard in both cycles. Post-intervention, there was an improvement in documentation for 12/17 of the parameters with marked improvements in indication for surgery (45% vs 75%), tourniquet time (20% vs 45%), antibiotic prophylaxis (71% vs 89%), closure technique (62% vs 86%) and detailed postoperative instruction (40% vs 92%). Other parameters, particularly estimated blood loss (7% vs 8%) remained unchanged. In the second cycle, we noted that 25% of the typed notes had 100% compliance with the standards, whereas no handwritten note achieved this. However, there was no statistically significant difference in the mean number of correctly documented parameters between the typed and handwritten notes (p < 0.05). ConclusionThe use of operation note templates (preferably typed) can improve appropriate documentation in orthopedic trauma operation notes. These templates should be made easily accessible to all surgeons. We will recommend orthopedic trauma units to apply similar non-rigid templates that can be tailored to suit different categories of trauma surgery.

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Section: Discussionmentioning

confidence: 99%

A Closed-Loop Audit for Orthopedic Trauma Operation Notes Comparing Typed Electronic Notes With Handwritten Notes

Anazor¹,

Sibanda²,

Abubakar³

et al. 2022

Cureus

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“…Only a few reports on surgical education for THA have been reported in the literature (10–11–12–13), and none are available on periacetabular osteotomy. Therefore, the objective of the present study was to verify whether trainees acquire satisfactory techniques under appropriate guidance.…”

Section: Introductionmentioning

confidence: 99%

Surgical Education of Eccentric Rotational Acetabular Osteotomy for HIP Trainees

et al. 2016

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“…Previous audits (Shayah et al 2007, Singh et al 2012 have shown notable improvements to documentation through the simple means of education about the Royal College of Surgeons guidelines. Other audits (Menakaya et al 2013, Sweed et al 2014 have specifically audited orthopaedic operation notes, and both concluded that proformas and aide memoirs would improve documentation. One further audit (Ghani et al 2014) noted an improvement in documentation when an electronic operation note system was introduced.…”

Section: Introductionmentioning

confidence: 99%

Improving Operation Notes and Postoperative Care: An Audit of Current Practice

Whitehead-Clarke

Varma

Hadjimichael

et al. 2015

Journal of Perioperative Practice

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The operation note is the single most important document in surgical practice. Ninety one operation notes were assessed on their adherence to guidelines, as well as their legibility and ability to inform postoperative care; as judged by five different healthcare professionals. Results showed a deficiency in essential information and poor legibility overall. Re-audit of 103 operation notes after intervention showed an improvement in nearly all criteria measured. The results indicate that education about current guidelines and an increase in word processing of operation notes improves quality of documentation, and therefore of postoperative care.

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Quality of operation notes in orthopaedic hip arthroplasty surgery: Are we complying with British Orthopaedic Association's guide to good practice?

Cited by 3 publications

References 3 publications

A Closed-Loop Audit for Orthopedic Trauma Operation Notes Comparing Typed Electronic Notes With Handwritten Notes

A Closed-Loop Audit for Orthopedic Trauma Operation Notes Comparing Typed Electronic Notes With Handwritten Notes

Surgical Education of Eccentric Rotational Acetabular Osteotomy for HIP Trainees

Improving Operation Notes and Postoperative Care: An Audit of Current Practice

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