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

Abstract

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.

Assessment of manual operation note documentation practice: a cross-sectional study

“…In this study, the type of anesthesia and intraoperative findings were documented in more than 90% of the notes that we investigated, and this was comparable with previous studies 26 . Position of the patient, type of incision, operative diagnosis, and closure technique were less frequently documented, which was lower than the rates observed in the previously mentioned studies conducted in Nigeria (82%) 25 and comparable with the study conducted in Pakistan (69%) 24 , but higher than the proportion observed in the study carried out in Sudan (26.9%) 20 .…”

“…RCSE guidelines stipulate that both date and time should be recorded in operation notes; this was consistently documented at the hospital under study. Contrary to this, the time of surgery was commonly omitted in operation notes evaluated by investigators in Nigeria and Pakistan 24 , 25 ; however, a study conducted in Sudan found that the time was documented in 81% of notes 20 .…”

Self-assessment of operation notes writing amongst residents in a teaching hospital

“…This may give room for errors/omissions in the notes especially in situations where the notes are written, unsupervised, by assistants who may not have clearly grasped the 3,5 operative procedure. Other studies from Nigeria showed that senior registrars are the main writers of [11][12][13][14] operation notes in all the centers. This was irrespective of whether they were the operating surgeons or not.…”

“…The feedback from this study should therefore help in formative assessment and education from the self-mirroring effect. There are studies from Nigeria on the audit of operation notes [11][12][13][14] writing in tertiary centers. The authors have not however seen any assessment based solely on trainees self assessment.…”