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

Abstract

Background: Operation notes documentation captures the key findings and subtle elements of a surgical strategy and is crucial for patient safety. Poor operation note documentation can negatively influence post-operative patient care. This study aimed to assess manual operation note documentation practice. Methods: An institutional-based, cross-sectional study was conducted from March 30 to April 30, 2022, on 240 operation notes of patient data. Data was entered and analyzed by SPSS version 20. According to RCSE Royal College of Surgeons of England, the practice of operation note documentation rated excellent for each variable when it met 100%, good if it was met in more than 50%, and poor if it met in less than 50% of operation notes of patient data. Results: All operation notes (n=240) were handwritten. The practice of manual operation note documentation was deemed excellent in two (7.69%), good in 18 (69.2%), and poor in six (23.1%). Residents wrote 84.2% of the operation notes and surgeons and assistants were identified in >94% of the notes, while anesthesia team members were identified in 90.8%. Estimated blood loss was documented in 4.2% of the notes, and the closure technique was described in 64.2%. The operation note templates did not include antibiotic prophylaxis, runner nurse name, or gauze and instrument counts. The urgency of the surgery and time of documentation had a negative relationship, and the seniority of the operation note writer had a positive relationship with manual operative note documentation practice. Conclusions and recommendation: Compared to the standard, all operation note documentation were incomplete and below the standard. We recommend that this comprehensive and specialized hospital administrator implement a new format for operation notes that incorporates RCSE requirements.