Improving the Quality of Oral and Maxillofacial Surgical Notes in an Indian Public Sector Hospital in Accordance with the Royal College of Surgeons Guidelines: A Completed Audit Loop Study

Abstract

Aim Proper and adequate documentation in operation notes is a basic tool of clinical practice with medical and legal implications. An audit was done to ascertain if oral and maxillofacial surgery operative notes in an Indian public sector hospital adhered to the guidelines published by the Royal College of Surgeons England. Methods Fifty randomly selected operative notes were evaluated against the guidelines by RCS England with regards to the essential generic components of an operation note. Additional criteria relevant to oral and Maxillofacial Surgery were also evaluated. Changes were introduced in the form of Oral and Maxillofacial Surgery specific consent forms, diagram sheets and a computerized operation note proforma containing all essential and additional criteria along with prefilled template of operative findings. Reaudit of 50 randomly selected operation notes was performed after a 6 month period. Results In the 1st audit cycle, excellent documentation ranging from 94 to 100 % was seen in 9 essential criteria. Unsatisfactory documentation was observed in criteria like assistant name, date of surgery. Most consent forms contained abbreviations and some did not provide all details. Additional criteria specific to Oral and Maxillofacial Surgery scored poorly. In the 2nd Audit for loop completion, excellent documentation was seen in almost all essential and additional criteria. Mean percentage of data point inclusion improved from 84.6 to 98.4 % (0.001\ P value \0.005). The use of abbreviations was seen in only 6 notes. Conclusion Regular audits are now considered a mandatory quality improvement process that seeks to improve patient care and outcomes. To the best of our knowledge, this is the first completed audit on operation notes documentation in Oral and Maxillofacial Surgery from India. The introduction of a computerized operation note proforma showed excellent improvement in operation note documentation. Surgeons can follow the RCS guidelines to ensure standardization of operation notes.

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

“…Parameters such as operative diagnosis, complications, details of additional procedures, specifics of tissue manipulation, prosthesis identification, closure technique details, anticipated blood loss, and antibiotic and thromboembolism prophylaxis achieved compliance rates of 85%, 98%, 88%, 79%, 37%, 99%, 92%, 96%, and 98%, respectively. Our study findings align with similar investigations [ 3 , 12 - 14 ] where the implementation of a revised surgical pro forma led to a substantial increase in adherence to RCS guidelines.…”

Surgeons' perspectives on operation report documentation

“…14 Studies show that formalized teaching programs to introduce a new synoptic proforma, such as the RCS standards, have significantly improved documentation across surgical specialities. [16][17][18][19][20][21][22][23][24][25][26] However, writing a complete operation report with a checklist prompt does not always infer the acquisition of these skills or the trainee's understanding of the surgery. 1 Gur et al explored the educational value of synoptic report writing and concluded that using a proforma specifically highlights to trainees the essential steps of an operation and, if wellconstructed, can improve trainee familiarity with the patient's preand intra-operative findings.…”

“…From prior studies, the importance of complete operation documentation is undervalued in surgical training, 11,14,15 and 34% of responding Surgical Program Directors in The United States of America perceive formal education in operation report writing is not required 14 . Studies show that formalized teaching programs to introduce a new synoptic proforma, such as the RCS standards, have significantly improved documentation across surgical specialities 16–26 . However, writing a complete operation report with a checklist prompt does not always infer the acquisition of these skills or the trainee's understanding of the surgery 1 .…”

Customized Tray for Impression Taking in Children With Cleft Lip and Palate

“…This documentation is an extremely important step for rehabilitation, allowing clinical evaluation of treatments, 1,2 for educational purposes, 3 research, comparison of treatment centers, 4 and legal records. 5,6…”

“…This documentation is an extremely important step for rehabilitation, allowing clinical evaluation of treatments, 1,2 for educational purposes, 3 research, comparison of treatment centers, 4 and legal records. 5,6 In the rehabilitation protocol of the Hospital of Rehabilitation of Craniofacial Anomalies/USP (HRAC/USP), impression of dental arches is obtained at about before lip repair-3 months, before palate repair-12 months and 1 year after primary surgeries. 7 However, in practice, commercial trays do not possess correct size and shape to be used in dental arches of infants with cleft lip and palate, precluding the proper impression of these patients, because the tray size is bigger than the children's maxilla.…”