Abstract
Introduction
The Royal College of Surgeons (RCS) published the Good Surgical Practice guidelines in 2008 and subsequently revised them in 2014. Essentially, they outline the basic standards that need to be met by all surgical operation notes. The objective of the present study was to retrospectively audit the orthopaedic operation notes from a tertiary care hospital in Mumbai (between October 2020 to March 2021) against the recommended RCS Good Surgical Practice guidelines published in 2014.
Method
In the present study a total of 153 orthopaedic operation notes of 200 patients were audited by a single reviewer. During the period between October 2020 and March 2021, the data collection took place. All notes were typed on the standard operative proforma available on the hospital patient management software (SAP).
Results
Overall, the mandated fields in the EMR had excellent documentation. Documentation was excellent for the date and time of surgery, name of the surgeon, the procedure performed (100%), operative diagnosis (99.35%), an extra procedure performed (100%), and details of antibiotic prophylaxis (99.35); Inadequate for details of incision (94.77%), details of operative findings (92.16%), details of prosthesis (97.37%), DVT prophylaxis (96.08%) and detailed post-operative instructions (93.46%) and poor for tourniquet time (41.83%;), estimated blood loss (59.48%), closure details (16.99%), documentation of complications or lack of (51.63%) and setting of surgery elective or emergency (0%).
Conclusion
Compliance for completion and documentation of operative procedures was high in some areas; improvement is needed in documenting tourniquet time, prosthesis and incision details, and the location of operative diagnosis and postoperative instructions. With wider adoption of electronic medical record systems, there is a scope of improving documentation by mandating certain fields.
Similar content being viewed by others
References
Organisation WH. (2008). Patient Safety Workshop LEARNING FROM ERROR.
Catchpole, K., Panesar, S., Russel, J., Tang, V., Hibbert, P., Cleary, K. (2009). Surgical safety can be improved through better understanding of incidents reported to a national database. Nat Patient Safety Agency
Payne, K., Jones, K., & Dickenson, A. (2011). Improving the standard of operative notes within an oral and maxillofacial surgery department, using an operative note proforma. Journal of Maxillofacial and Oral Surgery, 10, 203–208.
Al Hussainy, H., Ali, F., Jones, S., McGregor-Riley, J., & Sukumar, S. (2004). Improving the standard of operation notes in orthopaedic and trauma surgery: The value of a proforma. Injury, 35, 1102–1106.
Morgan, D., Fisher, N., Ahmad, A., & Alam, F. (2009). Improving operation notes to meet British Orthopaedic Association guidelines. Annals of the Royal College of Surgeons of England, 91, 217.
RCSEng. (2014). Good Surgical Practice
BOA/BASK. (1999). Knee replacement: a guide to good practice
Sweed, T., Bonajmah, A., & Mussa, M. (2014). Audit of operation notes in an orthopaedic unit. Journal of Orthopaedic Surgery, 22, 218–220. https://doi.org/10.1177/230949901402200221
Ghosh, A. (2010). An audit of orthopedic operation notes: What are we missing? Clinical Audit, 2, 37–40.
Bateman, N. D., Carney, A. S., & Gibbin, K. P. (1999). An audit of the quality of operation notes in an otolaryngology unit. Journal of the Royal College of Surgeons of Edinburgh, 44, 94–95.
Baigrie, R. J., Dowling, B. L., Birch, D., & Dehn, T. C. (1994). An audit of the quality of operation notes in two district general hospitals. Are we following Royal College guidelines? Annals of the Royal College of Surgeons of England, 76(1), 8–10.
Mustafa, M. K. E., Khairy, A. M. M., & Ahmed, A. B. E. (2020). Assessing the quality of orthopaedic operation notes in accordance with the royal college of surgeons guidelines: an audit cycle. Cureus., 12(8), e9707.
Barritt, A. W., Clark, L., Cohen, A. M., Hosangadi-Jayedev, N., & Gibb, P. A. (2010). Improving the quality of procedure-specific operation reports in orthopaedic surgery. The Annals of The Royal College of Surgeons of England, 92, 159–162.
(2008). WHO’s patient-safety checklist for surgery. Lancet. 372
Fudickar, A., Hörle, K., Wiltfang, J., & Bein, B. (2012). The effect of the WHO surgical safety checklist on complication rate and communication. Deutsches Ärzteblatt International, 109(42), 695–701. https://doi.org/10.3238/arztebl.2012.0695
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
No conflict of interest.
Ethical approval
This article does not contain any studies with human or animal subjects performed by the any of the authors.
Informed consent
For this type of study informed consent is not required.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Tuteja, S., Tiwari, A., Bhanushali, J. et al. Results of an Audit of Orthopaedic Operation Notes from a Tertiary Care Centre: Are We Doing It Right and Can We Do More?. JOIO 56, 2223–2227 (2022). https://doi.org/10.1007/s43465-022-00765-7
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s43465-022-00765-7