Improving the quality of orthopaedic elective and trauma operative notes: A completed audit loop study

Abstract

Introduction: Good medical practice dictates that comprehensive documentation of all surgical procedures is paramount in maintaining a high standard of patient care. This study audited the quality of operative note keeping for elective and trauma procedures against the standards set by the British Orthopaedic Association (BOA) and The Royal College of Surgeons of England (RCSE) guidelines. Patients and methods: A retrospective assessment of the operative notes of every patient undergoing a total knee and hip replacement (elective cases) was carried out over a period of 2 months. Data recorded were compared against BOA guidelines. Within this time a randomised selection of trauma operative notes were also assessed, and the recorded data were compared against RCSE guidelines. Change in practice was implemented and the audit cycle completed. A total of 173 operative notes were evaluated. Results: There was a significant improvement (p-value < 0.05) in the quality of total knee replacement notes, with an increase in the percentage of data points from 68.6% to 93%. Similarly the quality of total hip replacement notes showed significant improvement (p-value < 0.01) with an increase in the percentage of data points from 67.5% to 86%. However trauma operative notes showed minimal improvement. Discussion: This study showed that the quality of elective operative notes was improved through surgeon education and the circulation of a guideline based electronic operative note. We have further plans to implement procedure specific notes for the most common types of trauma cases to help improve the quality of trauma operative notes. Highlights

Improving the Standard of Orthopaedic Operation Documentation Using Typed Proforma Operation Notes: A Completed Audit Loop

“…A heading or specific textbox for the serial numbers may present a solution to this and one that would be easy to implement. Shah, et al also reported low documentation numbers for serial numbers of prostheses used in orthopaedic surgeries [6]. Their numbers were lower initially but did improve on re-audit whereas our numbers remained low.…”

“…Proforma benefits pertaining to operative documentation have been highlighted in other surgical specialties previously [11-12]. Shah, et al have shown statistically significant improvement in orthopaedic operation note documentation when using the British Orthopaedic Association guidelines and the RCS guidelines as a template for their total knee replacement (TKR) and total hip replacement (THR) operation notes [6]. …”

“…Typed notes afford a clear and concise operation note which can be interpreted accurately by a large number of people. Typed and handwritten proformas that are specific to specific surgeries or to surgical specialties have been shown to increase compliance with the RCS guidelines [5,6-7]. They may also assist in training surgical trainees and act as a teaching aid for procedures [8].…”

The quality of hand-written operative notes in a surgical unit at Queen Elizabeth Central Hospital (QECH), Malawi: A prospective completed audit loop study

“…Many electronic health systems enforce compliance by using drop down selections with failure to close pop out windows if incompletely filled14. Introduction of an electronic based template improves the standards of documentation and education of surgeons18,19. The major limitation of this study is that, although the operative notes written by the authors were excluded to counteract and eliminate bias, the unavailability of a second independent assessor for collateral and simultaneous assessment of the operative notes opens to analytical biasness.…”

Getting it right first time (GIRFT): A closed loop study of hip arthroplasty documentation in a trauma and orthopaedic department

“…To date, there have been studies looking into documentation in orthopaedics against BOA guidelines [ [6] , [7] , [8] ], 2008 RCS Good Surgical practice guidelines [ 9 , 10 ] and 2014 RCS Good Surgical Practice guidelines [ 8 , 11 ]. However, to our knowledge we are the first orthopaedic unit to study documentation of hip arthroplasty against July 2019 GIRFT, BHS and BOA guidance.…”