Quality of Operation Notes in Niger-Delta University Teaching Hospital, Southern Nigeria

,

doi:10.9790/0853-1030508

Cited by 2 publications

(4 citation statements)

References 7 publications

(10 reference statements)

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“…This may give room for errors/omissions in the notes especially in situations where the notes are written, unsupervised, by assistants who may not have clearly grasped the 3,5 operative procedure. Other studies from Nigeria showed that senior registrars are the main writers of [11][12][13][14] operation notes in all the centers. This was irrespective of whether they were the operating surgeons or not.…”

Section: Characteristics Of the Sampled Populationmentioning

confidence: 99%

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Self-assessment of operation notes writing amongst residents in a teaching hospital

Okugbo SU,

Agbonrofo PI

2019

Ibom Med J

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Context: Operation note writing is an integral part of the surgical procedure and chronicles the details surrounding it.Objective of the study: Is to determine the level of adherence of the surgical residents to standard guidelines on operation note writing.Subjects and Methods: This is a cross-sectional survey of residents in the department of surgery, University of Benin Teaching Hospital, Benin City, using an anonimised self-administered questionnaire, which was adopted from the Royal College of Surgeons guidelines on operation note writing.Results: Thirty-one residents (19 Senior Registrars and 11 Registrars) were sampled. 51.6% of respondents were 1year or less in training. 71.7% of respondents regularly write operation notes, however 90.1% of respondents reported that the first assistant wrote operation notes; while 74.2% reported that they adhere to standard guidelines operation note writing. Date, name of surgeon and assistants, type of operative procedure, incision and findings were universally reported amongst respondents, whereas names of scrub nurses, time, prosthesis serial number, deep venous thrombosis and antibiotic prophylaxis were poorly reported. Only 3 respondents scored 100% with the mean score of 75.4% of identified parameters in the guideline used.Conclusion: Training on operation note writing should be entrenched to ensure proper adherence to standard guidelines. Formative assessments of the process are imperative to improve compliance.

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Section: Characteristics Of the Sampled Populationmentioning

confidence: 99%

“…The feedback from this study should therefore help in formative assessment and education from the self-mirroring effect. There are studies from Nigeria on the audit of operation notes [11][12][13][14] writing in tertiary centers. The authors have not however seen any assessment based solely on trainees self assessment.…”

Section: Introductionmentioning

confidence: 99%

Self-assessment of operation notes writing amongst residents in a teaching hospital

Okugbo SU,

Agbonrofo PI

2019

Ibom Med J

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“…Operation notes pertaining to emergency general surgery (EGS) were selected in this study as this is a high-risk proportion making up more than one-third of all general surgical admissions (8). These complex surgeries carry eight times high mortality compared to elective surgical admissions (9). Poor records can potentially have medico-legal ramifications as well as effecting patients care which is increasingly becoming more relevant in today's litigious climate (9).…”

Section: Introductionmentioning

confidence: 99%

“…These complex surgeries carry eight times high mortality compared to elective surgical admissions (9). Poor records can potentially have medico-legal ramifications as well as effecting patients care which is increasingly becoming more relevant in today's litigious climate (9). Our primary aim was to assess the standard of EGS operation notes in accordance with the RCSEng guidelines at a single district general hospital.…”

Section: Introductionmentioning

confidence: 99%

Assessing the standard of emergency general surgical (EGS) operation notes in accordance with the Royal College of Surgeons guidelines

Zuberi,

Mustaq,

Ijaz

et al. 2024

Turk J Surg

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Objective: Operation notes are important for care in surgical patients. The objectives of this study were to analyze the emergency general surgery (EGS) operation note documentation in accordance with the Royal College of Surgeons of England (RCSEng) guidelines and to assess the impact of creating awareness of the guidelines and effect of a new proforma. Material and Methods: A retrospective review of 50 EGS operation notes was conducted between December 2019 and March 2020 and compared to RCSEng guidelines. Education was delivered on the importance of documentation in accordance with RCSEng guidelines. A new electronic proforma was introduced. A further 50 EGS operation notes were analysed between August 2020 and December 2020. Results: One hundred operation notes were reviewed, and each given a score out of 19. Our interventions showed significant improvement to the average score (15.64 vs 17.96; p< 0.001). Within the second cycle, there was a statistically significance difference when comparing electronic to handwritten notes (18.55 vs 17.50; p= 0.001). Conclusion: Implementation of the new proforma showed improvement in operation note documentation when compared to the RCSEng standard. Therefore, this study emphasizes the need for surgeons to familiarize themselves with the current guidelines.

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Quality of Operation Notes in Niger-Delta University Teaching Hospital, Southern Nigeria

Cited by 2 publications

References 7 publications

Self-assessment of operation notes writing amongst residents in a teaching hospital

Self-assessment of operation notes writing amongst residents in a teaching hospital

Assessing the standard of emergency general surgical (EGS) operation notes in accordance with the Royal College of Surgeons guidelines

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