A prospective closed loop audit on the quality of the operative notes in a general surgical unit in a quaternary care centre

Javid, Mohamed; Swaminathan, Shanthi Ponnandai; Jebasingh, Arun Victor; Velayutham, Manivannan; Mani, Rajeswari

doi:10.18203/2349-2902.isj20200049

Cited by 5 publications

(4 citation statements)

References 2 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…In our closed loop audit, we found that testing practices against standards and subsequent re-auditing lead to significant improvement in practices. Similar results were noted by other authors who have found that documentation of operative notes significantly improved in the re-audit as compared to the initial audit [4,5,7,8].…”

Section: Discussionsupporting

confidence: 88%

“…In 2014, the Royal College of Surgeons of England introduced good surgical practice guidelines, which outline information that should be present in operative notes [3]. These guidelines are considered the standard against which the performance of several institutes has been audited previously [4][5][6][7][8][9]. The purpose of this audit was to evaluate the quality of operative notes against this recognized standard, identify pitfalls and make recommendations to improve operative notes in the Department of Surgery at Arif Memorial Hospital, Lahore.…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Audit of Operative Notes Against Royal College of Surgeons Guidelines in a Tertiary Health Care Surgical Unit in Lahore

Khalid¹,

Shahzad²,

Ahmed³

et al. 2022

Cureus

View full text Add to dashboard Cite

Operative notes are important documentation made by the surgical team after a surgical procedure. They outline what happened during the surgery and several aspects of post-operative instructions. The aim of this audit was to compare current practices regarding documentation of these operative notes in a tertiary care hospital in Lahore. The standards used were the recommendations made in the good surgical practice guidelines by the Royal College of Surgeons (RCS) of England in 2014.A prospective closed-loop audit was conducted using a checklist constructed using the RCS guidelines. In the first audit, which was done to analyze current practices, 44 consecutive handwritten operative notes were evaluated. The findings of this initial audit were presented to the surgical team in a local meeting and recommendations were made. Forty-eight consecutive operative notes were then analyzed in the re-audit done after an interval of one month. The findings of the re-audit were presented to the surgical team.An overall 35.7% improvement was noted in the documentation of operative notes after the completion of the audit cycle. Certain parameters analyzed, such as thromboprophylaxis, antibiotic prophylaxis, and anticipated blood loss, were much more frequently documented in the re-audit.In our study, implementation of recommendations such as restructuring of the operative notes pro forma and improving awareness regarding the RCS guidelines significantly improved the quality of operative notes that were being documented. Such audits should be conducted regularly to maintain and improve the standards of documentation in all surgical units.

show abstract

Section: Discussionsupporting

confidence: 88%

Section: Introductionmentioning

confidence: 99%

Audit of Operative Notes Against Royal College of Surgeons Guidelines in a Tertiary Health Care Surgical Unit in Lahore

Khalid¹,

Shahzad²,

Ahmed³

et al. 2022

Cureus

View full text Add to dashboard Cite

show abstract

“…A previous study assessed the quality of operation notes and found that the RCSEng guidelines were not followed properly (11). During the second cycle, the intervention of raising awareness about the guidelines and creating a proforma was effective in improving the average score per operation note to 17.96/19 (94.53%).…”

Section: Discussionmentioning

confidence: 95%

Assessing the standard of emergency general surgical (EGS) operation notes in accordance with the Royal College of Surgeons guidelines

Zuberi,

Mustaq,

Ijaz

et al. 2024

Turk J Surg

View full text Add to dashboard Cite

Objective: Operation notes are important for care in surgical patients. The objectives of this study were to analyze the emergency general surgery (EGS) operation note documentation in accordance with the Royal College of Surgeons of England (RCSEng) guidelines and to assess the impact of creating awareness of the guidelines and effect of a new proforma. Material and Methods: A retrospective review of 50 EGS operation notes was conducted between December 2019 and March 2020 and compared to RCSEng guidelines. Education was delivered on the importance of documentation in accordance with RCSEng guidelines. A new electronic proforma was introduced. A further 50 EGS operation notes were analysed between August 2020 and December 2020. Results: One hundred operation notes were reviewed, and each given a score out of 19. Our interventions showed significant improvement to the average score (15.64 vs 17.96; p< 0.001). Within the second cycle, there was a statistically significance difference when comparing electronic to handwritten notes (18.55 vs 17.50; p= 0.001). Conclusion: Implementation of the new proforma showed improvement in operation note documentation when compared to the RCSEng standard. Therefore, this study emphasizes the need for surgeons to familiarize themselves with the current guidelines.

show abstract

“…The study aimed to assess the surgical practices at HMC based on 19 parameters outlined in the 2014 operative note guidelines for good surgical practice established by the RCS [ 8 ]. These parameters provided a comprehensive framework for evaluating various aspects of surgical documentation and care.…”

Section: Methodsmentioning

confidence: 99%

Assessing Adherence to Royal College of Surgeons Guidelines: A Closed-Loop Audit of Operation Notes in a Tertiary Healthcare Unit

Zahid,

Ijaz,

Hidayat

et al. 2023

Cureus

View full text Add to dashboard Cite

Introduction Accurate, comprehensive, and legible operation notes are essential for maintaining patient records, supporting healthcare professionals, and facilitating research. The study focused on adherence to Royal College of Surgeons (RCS) guidelines established in 2008. Despite the guidelines, poor documentation practices have been reported globally. This audit seeks to address this issue and enhance documentation quality. Methodology The audit evaluated 19 parameters as defined in the 2014 RCS operative note guidelines. Data collection occurred during the initial cycle, spanning from March to April 2023, encompassing all surgical procedures at Hayatabad Medical Complex (HMC). Subsequently, a re-audit took place in July 2023 to gauge enhancements following a survey and educational intervention that took place in June 2023. The process included the formation of an audit team, securing ethical approval, and implementing a comprehensive methodology for data collection and analysis. The study spanned two data collection cycles to comprehensively assess improvements. Results Comparing initial and re-audit cycles (n = 390 and n = 108, respectively), improvements were observed in several documentation aspects. Parameters such as surgery date, elective/emergency classification, and names of key personnel showed significant enhancement. Notable improvements were also seen in the recording of operative details, complications, extra procedures, and post-operative care instructions. In our department, an educational survey was conducted to gain insights into compliance rates. This survey underscored the significance of adhering to RCS guidelines, identified the factors influencing adherence, and proposed strategies for improvement. Conclusion The audit affirmed the significance of adhering to RCS guidelines for operation note documentation. The study demonstrated improvements in documentation practices, emphasising the importance of accurate records for patient care, research, and ethical standards. The findings validate RCS guidelines as a tool for the identification of defects in documentation and thus as a guide that highlights where improvements are necessary. Addressing challenges identified in this audit can drive the department towards becoming a model for RCS guideline adherence and showcasing high-quality surgical documentation and patient-centred care.

show abstract

A prospective closed loop audit on the quality of the operative notes in a general surgical unit in a quaternary care centre

Cited by 5 publications

References 2 publications

Audit of Operative Notes Against Royal College of Surgeons Guidelines in a Tertiary Health Care Surgical Unit in Lahore

Audit of Operative Notes Against Royal College of Surgeons Guidelines in a Tertiary Health Care Surgical Unit in Lahore

Assessing the standard of emergency general surgical (EGS) operation notes in accordance with the Royal College of Surgeons guidelines

Assessing Adherence to Royal College of Surgeons Guidelines: A Closed-Loop Audit of Operation Notes in a Tertiary Healthcare Unit

Contact Info

Product

Resources

About