The quality of operative note taking: an audit using the Royal College of Surgeons Guidelines as the gold standard

Abstract

To assess the quality of operative note keeping and compare the results with the Royal College of Surgeons (RCS) of England guidelines 'Good Surgical Practice' as the gold standard. ENT Department at Hull Royal Infirmary, University Hospital. A hundred consecutive operative notes were selected between November 2005 and January 2006. The documentation of the operative notes in each case was compared with the RCS of England guidelines. All surgeons were made aware of the results of the first cycle and the guidelines were made available in all ENT theatres in the form of a printed aide-memoir. A second audit cycle was then carried out prospectively between April and June 2006. The results demonstrated a change in practice in key areas. The 1st cycle results showed the documentation of patient identification (94%), name of surgeon (98%) and clearly written postoperative instructions (94%). However, surgeons performed suboptimally at recording the name of assistant (82%), operative diagnosis (46%), the incision type (87%) and the type of wound closure (83%). After introducing the aide-memoir, the second cycle demonstrated a change in practice with 100% documentation in most of the assessed parameters except that the time of surgery and the type of surgery (emergency or elective) were not adequately recorded. We recommend that all surgical departments should have the RCS guidelines as an aide-memoir in theatres to enhance the quality and standardise operative note recording.

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“…If a nurse waits until the end of a shift to document the day's events, it can be difficult to recreate an accurate sequence of events. Documenting events as they occur guarantees that important information about the patient's condition and care is not forgotten if subsequent events take place 52,54 …”

“…Documenting events as they occur guarantees that important information about the patient's condition and care is not forgotten if subsequent events take place. 52,54…”

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Engaging clinicians in evidence based policy development: The case of nursing documentation

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