Abstract
The operative note is a vital document in the treatment and safety of patients. Detailed recording of operation notes can be quite helpful in research, audit and medico-legal problems. This quality improvement programme was conducted to assess the quality of documentation on an electronic template in comparison to the Royal College of Surgeons (RCS) guidelines. The electronic template used for recording operation notes was compared with RCS guidelines for completeness. A retrospective review of operation notes for all the operations performed by ENT over 1-month period was done. The deficiencies were shared with the department during monthly quality-improvement meetings. A second cycle was carried out in the month of September. The electronic template that is being used in our hospital matches completely with the RCS recommendation. A total of 90 operative records were analysed in the initial audit. The Compliance was 100% in all parameters except five. In the second cycle of audit, compliance was found to be 100% across all parameters, except one—showing considerable improvement. Electronic templates offer easy recording of operation notes without the help of aide memoire, despite which deficiencies do occur. Regular audits are needed to maintain good record-keeping.
Similar content being viewed by others
References
Good Surgical Practice. Royal College of Surgeons (2014) https://www.rcseng.ac.uk/standards-and-research/gsp/domain-1/1-3-record-your-work-clearly-accurately-and-legibly/
Morgan D, Fisher N, Ahmad A, Alam F (2009) Improving operation notes to meet British Orthopaedic Association guidelines. Ann R Coll Surg Engl 91(3):217–219. https://doi.org/10.1308/003588409X359367
Nyamulani N, Mulwafu W (2018) The quality of hand-written operative notes in a surgical unit at Queen Elizabeth Central Hospital (QECH), Malawi: a prospective completed audit loop study. Malawi Med J 30(2):86–89. https://doi.org/10.4314/mmj.v30i2.6
Shayah A, Agada FO, Gunasekaran S, Jassar P, England RJ (2007) The quality of operative note taking: an audit using the Royal College of Surgeons Guidelines as the gold standard. Int J Clin Pract 61(4):677–679. https://doi.org/10.1111/j.1742-1241.2007.01292.x (PMID: 17394439)
Theivendran K, Hassan S, Clark ID (2016) Improving the quality of operative notes by implementing a new electronic template for upper limb surgery at the Royal Derby Hospital. BMJ Open Qual. https://doi.org/10.1136/bmjquality.u208727.w349
Severn Audit and Research Collaborative in Orthopaedics (2016) Assessing the quality of operation notes: a review of 1092 operation notes in 9 UK hospitals (Erratum in: Patient Saf Surg. 2016;10:8. PMID: 26855672; PMCID: PMC4744456). Patient Saf Surg. 10:5. https://doi.org/10.1186/s13037-016-0093-x
Atrey A, Corbett SA, Gibb PA, Singh S, Jähnich H (2010) Interactive computer operative notes for arthroscopy of joints: a free and accurate tool for surgeons. Arthroscopy 26(6):853–860. https://doi.org/10.1016/j.arthro.2010.04.006 (PMID: 20511045)
Currall VA, Chesser TJ (2008) Computer generated operation notes. Stud Health Technol Inform 137:51–55 (PMID: 18560067)
O’Bichere A, Sellu D (1997) The quality of operation notes: can simple word processors help? Ann R Coll Surg Engl 79:204–208
Apparau D, Mohd S, Mohd A, Dick D, Trimble K (2016) Audit of operation notes from a single otorhinolaryngology unit: Does new template improve quality? Int J Surg 36(1):S86–S87. https://doi.org/10.1016/j.ijsu.2016.08.285
Funding
No funding needed.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
No conflict of interest to be declared.
Ethical approval
Ethical and Research clearance obtained from Clinical Effectiveness team at Sandwell and West Birmingham NHS trust (as it is an audit, separate ethical clearance not needed as per local policy—audit number 1207).
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Vijayakumar, S., Divakaran, S. & Khan, I. Audit on the Quality of Operation Notes in Otolaryngology: Based on Electronic Template. Indian J Otolaryngol Head Neck Surg 74, 439–441 (2022). https://doi.org/10.1007/s12070-021-02492-1
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12070-021-02492-1