Improving the standard of operation notes in orthopaedic and trauma surgery: the value of a proforma

Improving the Standard of Operative Notes within an Oral and Maxillofacial Surgery Department, using an Operative Note Proforma

“…A legible, well structured operative note is a part of best practice medical record keeping, and may prove important in medico-legal cases. Several previous studies have assessed the quality of operative notes [3][4][5][6][7][8], with all of these finding operative notes lacking in compliance to RCSE guidelines, or respective sub-speciality association guidelines. This represents the same conclusion this author found after our initial audit and the reason for our change in practice.…”

An audit of orthopedic operation notes: what are we missing?

“…Proformas have been shown to be of benefit in a number of specialities 1,5,9 as have aide-memoires. 7 The literature also provides evidence of the superiority of computerized operation notes compared to hand written notes 10 although these studies Clinical Audit is an international, peer-reviewed, open access journal focusing on the processes and outcomes of clinical audit in any area of healthcare.…”

“…The operative findings and post operative plans they contain, serve not only as a vital means of communication between health professionals, but are also the only legal record of an operation. 1 Its importance is recognized by the General Medical Council who state that good note keeping is an essential part of good medical practice 2 while the British Orthopedic Association state that "good records are a basic tool of clinical practice". 3 However, The National Confidential Enquiry into Perioperative Deaths 4 in the UK noted that orthopedic operative records were often inadequate describing examples as "untidy one liners".…”

“…Of these, three were relevant. 1,6,7 These studies included auditing only elective total knee replacement consent forms against British Orthopedic Association guidelines 6 and auditing all orthopedic operations at the institution against authors criteria.…”

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

“…These include an aide-memoire attached to the operation sheet, poster/ checklist in the operation theatre, or the use of an operative note proforma sheet (handwritten/computerized) [3,6,7]. The use of a proforma alerts the user to fill all the specified criteria with a resultant improvement in compliance to guidelines.…”