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

Payne, Karl; Jones, Keith; Dickenson, Andrew

doi:10.1007/s12663-011-0231-z

Cited by 20 publications

(23 citation statements)

References 5 publications

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“…They form an important part of patients case notes and hence the must be complete and legible. 5 Several previous studies have assessed the quality of operative notes, and all these studies, in their initial assessment have found that neither RCSE guidelines nor the respective sub-speciality association guidelines were fully followed properly. [5][6][7] This is similar to what we found after our initial audit and served as the reason for implementing a change in our practice.…”

Section: Discussionmentioning

confidence: 99%

A prospective closed loop audit on the quality of the operative notes in a general surgical unit in a quaternary care centre

et al. 2020

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Background: Proper documentation of the surgery done in the form of operative notes is a very important aspect of surgical practice. The aim of this clinical audit was to identify the existing standard of the operative notes written in a general surgical unit in a quaternary care hospital; and to compare it with the recommendations given by Royal College of Surgeons, England (in Good Surgical Practice, 2014) and if needed, to improve the standard of practice.Methods: In the first loop of this prospective audit, 75 consecutive operative notes which were written were compared with the RCS guidelines and the areas which had missing data were identified. These areas were informed to the residents, who are primarily involved in the documentation of the operative notes. The second loop of the audit was conducted after a gap of 4 months involving 75 consecutive operative notes again.Results: The areas which were initially deficient were better documented when analysed in the second loop.Conclusions: Documentation of operative notes does not always comply with the set guidelines as highlighted in the first loop of our audit. But by employing a clinical audit it is possible to identify the existing deficiencies and thereby improving the standards of practice. Also, operative note writing should be taught as part of surgical training. Definitions should be clearly provided, and specific guidelines should be established to improve the quality of the operative notes and their use to improve patient safety.

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Section: Discussionmentioning

confidence: 99%

A prospective closed loop audit on the quality of the operative notes in a general surgical unit in a quaternary care centre

et al. 2020

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“…The orthopaedic proforma used in Sheffield previously highlighted how the addition of these specialty-specific headings improved documentation [7]. 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].…”

Section: Discussionmentioning

confidence: 99%

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

Coughlan

Ellanti

Moriarty

et al. 2017

Cureus

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IntroductionThe Royal College of Surgeons (RCS) published Good Surgical Practice guidelines in 2008 and revised them in 2014. They outline the basic standard that all surgical operation notes should meet.ObjectivesTo retrospectively audit 57 typed orthopaedic operation notes from St. James’s Hospital in Dublin (from August to November 2015) against the RCS Good Surgical Practice guidelines published in 2014. They were then compared with the department’s previous audit of handwritten notes to complete the audit loop.Materials and methodsA total of 57 orthopaedic operation notes were audited by a single reviewer. They were prospectively collected between August and November 2015. All notes were typed on the standard St. James’s Hospital operation note proforma.ResultsOf the surgeries, 89.5% were emergencies with 77.2% of them being performed by trainees. All of the operation notes were typed and signed by trainees. The procedure name, incision and closure details, tourniquet time (when relevant), and postoperative instructions were documented in 100% of the notes. In total, 80.7% had an operative diagnosis included while only 26.9% of the documentation had prosthesis serial numbers. All of the typed notes were deemed to be legible.ConclusionThe use of printed operation notes allows for improved legibility when compared to typed notes. Documentation standards remained very high in the same areas as the handwritten notes and a marked improvement was seen in areas that had been poorly documented.

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“…In our study, 20% of the notes had illegible parts, similar to findings in other studies. 10,13 Legibility of signatures can be improved by the use of name stamps.…”

Section: Discussionmentioning

confidence: 99%

Audit of Operation Notes in an Orthopaedic Unit

Sweed

Bonajmah

Mussa

2014

J Orthop Surg (Hong Kong)

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Purpose. To audit operation notes of 50 patients according to the guidelines of the Royal College of Surgeons. Methods. Proforma operation notes of 50 consecutive patients treated in an orthopaedic department were audited by a single reviewer, according to the guidelines of the Royal College of Surgeons in terms of date and time of surgery, name of surgeon, procedure, operative diagnosis, incision details, signature, closure details, tourniquet time, postoperative instructions, complications, prosthesis used, and serial numbers. Results. There were 45 trauma cases and 5 elective cases. The operating surgeons were consultants (32%), senior registrars (36%), and registrars (32%). 28% and 72% of the operation notes were written by operating surgeons and assistants, respectively. Of the 14 operating surgeons who wrote their own notes, one was a consultant, 6 were senior registrars, and 7 were registrars representing 6%, 33%, and 2014;22(2):218-20 44% of the respective grades of surgeons. All the notes were handwritten; 20% had illegible parts (all in the description of the operative technique). Documentation was good for date and time of surgery (100%), name of surgeon (100%), procedure (100%), duration of surgery (94%), operative diagnosis (92%), incision details (84%), and signature (84%). Documentation was poor for tourniquet time (32%; pneumatic tourniquet was used in 25 patients, only 8 of whom were documented), closure details (16%), and postoperative instructions (24%). Conclusion. Documentation of operative details in our department was generally good, except for closure details, tourniquet time, and postoperative instructions. Journal of Orthopaedic Surgery

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

Abstract: Previous papers have discussed various methods of improving operative note standards. We present statistical evidence for the use of an Operative Note Proforma to improve operative note standards within Oral and Maxillofacial Surgery.

Cited by 20 publications

References 5 publications

A prospective closed loop audit on the quality of the operative notes in a general surgical unit in a quaternary care centre

A prospective closed loop audit on the quality of the operative notes in a general surgical unit in a quaternary care centre

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

Audit of Operation Notes in an Orthopaedic Unit

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