An audit of orthopedic operation notes: what are we missing?

Ghosh, Aloke

doi:10.2147/ca.s9665

Cited by 11 publications

(9 citation statements)

References 6 publications

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“…Audits from Nigeria and other part of Africa have demonstrated similar, and in some instances, poorer results [7][8][9] . Those from developed countries however showed marginally better results 1,10 .…”

Section: Discussionmentioning

confidence: 92%

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An audit of the quality of surgical operation notes in a Nigerian teaching hospital

Babalola¹,

Olasehinde²,

Sowande³

2016

East. Cent. Afr. J. Surg.

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Background: Operation note records are important tools for ensuring patients' continuity of care, for research purposes and medico-legal reasons. They can effectively serve these purposes only if well documented. The main objective of this study was to assess the practice of recording the operation notes among surgical trainees in a Nigerian Teaching Hospital. Methods: Operation notes completed by doctors in the Surgery Department over a 2-month period were audited for completeness, legibility and conformity to the standards of the Royal College of Surgeons of England. Results: There were 100 operation notes reviewed, two-thirds of these were written by Senior Registrars, majority of which were for elective operations (63%). Only 37 of the operation notes were appropriately completed with about two-thirds either incomplete or wrongly filled. The cadre of the surgical trainee did not significantly influence the completeness of the operation notes. Legibility of the operation notes was associated significantly with completeness (p<0.04). Conclusion: Standards of operation note writing in our practice needs to be improved upon. The challenges of legibility and completeness of documentation can be overcome by the use of an aide-memoire as well as computerized operation notes.

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Section: Discussionmentioning

confidence: 92%

“…Operative findings and post-operative plans contained in the notes do not onlyserve as a vital means of communication between health professionals, but are also the only legal record of an operation 1 .…”

Section: Introductionmentioning

confidence: 99%

An audit of the quality of surgical operation notes in a Nigerian teaching hospital

Babalola¹,

Olasehinde²,

Sowande³

2016

East. Cent. Afr. J. Surg.

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“…Well-written notes carry great importance in patient care, as they directly impact the follow-up care. The sole account of events occurring during surgery are operative notes [6]. Documentation is pivotal in surgery as circumstances may vary every second.…”

Section: Discussionmentioning

confidence: 99%

Royal College of Surgeons Guideline Adherence on Improvement of Operative Notes: A Six-Month Closed Loop Audit

Bhatti

Ahmad

Asad

2020

Cureus

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“…In our study, 20% of the notes had illegible parts, similar to findings in other studies. 10,13 Legibility of signatures can be improved by the use of name stamps.…”

Section: Discussionmentioning

confidence: 99%

“…In our study, 20% of the notes had illegible parts, similar to findings in other studies. 10,13 Legibility of signatures can be improved by the use of name stamps. 14 Although all our surgeons found that handwritten notes are easier and less time consuming, computerized notes avoid illegibility and help in medicolegal defence.…”

Section: Discussionmentioning

confidence: 99%

Audit of Operation Notes in an Orthopaedic Unit

Sweed

Bonajmah

Mussa

2014

J Orthop Surg (Hong Kong)

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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

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An audit of orthopedic operation notes: what are we missing?

Cited by 11 publications

References 6 publications

An audit of the quality of surgical operation notes in a Nigerian teaching hospital

An audit of the quality of surgical operation notes in a Nigerian teaching hospital

Royal College of Surgeons Guideline Adherence on Improvement of Operative Notes: A Six-Month Closed Loop Audit

Audit of Operation Notes in an Orthopaedic Unit

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