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

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.

Section: Discussionsupporting

confidence: 93%

“…In modern healthcare, adept record-keeping is imperative, especially when addressing concerns related to medical malpractice [ 3 - 5 ]. These notes not only act as crucial reference tools for healthcare practitioners dealing with patients' surgical histories but also hold potential relevance in legal proceedings [ 3 , 6 , 7 ].…”

Section: Introductionmentioning

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

“…We reviewed the existing literature for further comparison with our findings. A study by Khalid et al (September 19, 2022) [ 7 ] involved a similar issue at a tertiary hospital in Lahore and documented the following results after completing the audit (against the results from our study). Date of procedure: 100% vs. 100% in our study; time of the procedure: 87.5% vs. 6.25%; elective/emergency procedure: 100% vs. 50%; the name of surgeon and assistant: 100% vs. 100%; the name of the operative procedure: 97.9% vs. 100%; type of incision: 95.8% vs. 100%; operative diagnosis: 97.9% vs. 100%; operative findings: 95.8% vs. 100%; complications encountered: 93.8% vs. 90%; any extra procedure performed with reason: 93.8% vs. 75%; details of tissue removed, added, or altered: 93.8% vs. 71.8%; details of closure technique: 95.8% vs. 100%; anticipated blood loss: 95.5% vs. 9.3%; antibiotic prophylaxis: 97.9% vs. 28.1%; DVT prophylaxis: 60.4% vs. NA; detailed postoperative care instructions: 91.7% vs. 100%; and signature: 100% vs. 100%.…”

Section: Discussionsupporting

confidence: 68%

Improving the Quality of Operative Notes in Vascular Surgery: A Retrospective Analysis

Akasha,

Alfatih,

Mohamed

et al. 2024

Background and objective Missing information or mistakes in patients’ medical records, including those related to intraoperative and postoperative information, in an operative note can have profound clinical, ethical, and medicolegal implications. Operative notes should be informative, clear, and inclusive of the necessary data and should be collated immediately following surgery. In this study, we aimed to determine the ways to improve the quality of operative notes in the field of vascular surgery. Methods In this retrospective analysis, we compared the operative notes of 32 patients in the Department of Vascular and Endovascular Surgery, University Hospital Galway, against the standard set by the Royal College of Surgeons in Ireland (RCSI) (Code of Practice for Surgeons RCSI, 2018) and presented the results to our departmental staff. To facilitate an improvement in the quality of operative notes, a structured poster checklist was designed and displayed in the operating theatre. Furthermore, a scanner was set up in the operating theatre with clear and easy-to-follow instructions for uploading the operative notes into our hospital’s online and digital patient record system (EVOLVE). An explanatory video was circulated among the staff. Three months after the first cycle, two further retrospective cycles were performed. Results A total of 96 patients’ operative notes were analysed. Following the intervention, a significant improvement in documentation was noted concerning the dates; procedures followed; as well as the details of surgeons, assistants, anesthetists, incisions, surgery types, operative diagnoses, complications, additional procedures, tissue details, prostheses involved, closure techniques, postoperative plans, and surgeons’ signatures. We also observed a significant increase in the uploading of the operative notes in the EVOLVE system. Conclusions The quality of the operative notes improved considerably after staff education, poster display, and scanner installment in the operating theatre. It is important to have an efficient and well-structured plan to improve the process of operative note-keeping, thereby ultimately enhancing overall patient care.

“…Khalid et al employed a similar strategy in their audit of surgical operation notes, covering the same surgical procedures. The implementation of an enhanced proforma format significantly improved overall documentation accuracy, increasing details recorded from 58.6% to 95.3% in the notes [ 6 ]. The findings of this audit, coupled with the evidence presented, highlight the substantial enhancement achievable in patient care through the implementation of straightforward measures.…”

Section: Discussionmentioning

confidence: 99%

A Clinical Audit of Operation Notes Documentation and the Impact of Introducing an Improved Proforma: An Audit Cycle

Hassan,

Akbar,

Khan

et al. 2023

Introduction Accurate and comprehensive documentation of surgical procedures is vital in healthcare for both medical and legal purposes. This audit assessed adherence to international guidelines for operative note documentation in a general surgery department and the impact of introducing educational initiatives and an enhanced proforma. Methods A retrospective audit of 100 operative notes was conducted in April 2023, followed by a prospective re-audit of another 100 notes in October-November 2023. A checklist based on Royal College of Surgeons (RCS) guidelines assessed 20 parameters. An improved proforma and an awareness session for surgeons were implemented between audits. Data analysis utilized the IBM SPSS Statistics for Windows, Version 26.0 (Released 2019; IBM Corp., Armonk, New York, United States). A paired-sample t-test was used, and a p-value < 0.001 was considered statistically significant. Results The initial audit revealed discrepancies in documentation, with missing information on deep vein thrombosis (DVT) prophylaxis, elective/emergency settings, anticipated blood loss, closure technique specifics, and prosthesis/mesh details. Legibility was satisfactory in 88% of notes. After implementing the proforma and awareness session, significant improvements were observed in all parameters, with documentation rates exceeding 91%. Overall documentation completeness increased from 65.2% to 95.2%. Results of the paired-sample t-test indicated a significant difference before and after the introduction of the new proforma (Mean (M) = 65.2, standard deviation (SD) = 34.3 versus M = 95.2, SD = 4.3) with a p-value of 0.0005. Conclusion Regular audits, surgeon education, and standardized proformas are essential for maintaining high standards in operative note documentation, contributing to improved patient care and safety.