Orthopedic Operation Notes: What are we Missing?
Asian Journal of Orthopaedic Research,
Background: Accurate legible documentation of operation notes is core element of surgical practice in any Specialty. Complete comprehensive operation notes are also important for maintaining high standard of patient care and for defense in medico legal cases.
Aims: Objective of our study was to compare the quality of orthopedic trauma operation notes at our hospital with standard set by the Royal college of Surgeons , England (RCSE) 2008.
Materials and Methods: Retrospective review of 300 Orthopedic trauma surgery notes was carried out for the period 01/1/2017 to 31/12/2017.Additional variables not included in RCSE 2008 guidelines were included in results. The complete data collected was analyzed using SPCC 20 version.
Results: The demographic details as well as date, time of surgery, name of surgeon, assistant surgeon, anesthetist, scrub nurse and signature were documented well in nearly all cases. Notes were written by the lead surgeon in 80.6 % cases and 0.5% were consultant notes. Adequate document were; Implant usage in 62.5%, Postoperative instructions 96.6%, Intra operative complications, blood loss, ICD -10 coding were poorly documented while tourniquet time was not documented well.
Conclusion: Our study highlighted major deficiencies in some areas with good compliance in other areas. Therefore we suggest to use aide memoire and standard based Performa’s which will improve quality of operation notes and better follow up patient care.
- Medico legal cases
- surgical notes
- orthopedic trauma surgery
- blood loss
How to Cite
The Royal college of surgeons of England. Good Surgical Practice London. U.K. Professional standards and regulations; 2008.
Ghosh AK. An audit of operation notes: What we are missing. Clinical Audit. 2010;2:37-40.
NHS Litigation Authority:NHS litigation authority report and accounts. 2014/15; 2015.
Machin J, Briggis T. Litigation in trauma and orthopedics. JTO. 2014;02:32-8.
Kawu AA, Sha DG, Salami OOA, Olawepo A, Kuranga SA, Jeje EA. Operative notes in orthopaedic surgical care in Nigeria. Int J. Biol Med Res. 2011;2(3):668-670.
Malik SS, Nagaro MC, Shenoy R, Mitchell PD. Improving trauma operation notes at an emergency trauma unit in the Regional Trauma Network. Ann R Coll Surg Engl (supp). 2013;95.
Coughlan F, Ellanti P, Fhoghlu CN, Moriarity A, Hogan N. Audit of orthopedic surgical documentation. Surg Res Pract. 2015;2015:9-12. DOI: 10.1155/2015/782720
Hamza AA, Abdalrahmi HM, Idris SA, Ahmed OM. Evaluating the operation notes of patients undergoing Surgery at Omdurman Teaching Hospital, Sudan. Sch. J. App. Med. Sci. 2013;1(6):668- 672.
Jawed M, Askari R, Qureshi MA, Manzar S. Quality of operative notes. Journal of Post graduate Medical Institute (Peshawar- Pakistan). 2011;22(4):174-176.
Elfaki EAA, Elhilu AH. Facts about compliance of surgeons. An audit study of the quality of operation notes in the department of general surgery, King Faisal Hospital, Makkah, Saudi Arabia. Sudan JMS. 2009;4(1):12-16.
Waben LSGL, Goossens RH, Lange JF. Evaluation of operative notes concerning laproscopic cholecystectomy: Are standards being met? World J Surg. 2010;34(5):903-909.
Mathew J, Baylis C, Saklani AP, Al- Dabbagh AR. Quality of operative notes in a district general hospital: A time for change? Internet J. Surg. 2003;5:116–19.
Abbas SH, Singh S, Sundran R, Akbari K, Gilmour J , Puttick M. A thorough note: Does a procedure-specific operation note proforma for laparoscopic appendicectomy improve compliance with the Royal College of Surgeons of England Guidelines? International Journal of Surgery Open. 2016;2:1–5.
Mattawanon N, Srisomboon J, Kletpeerakool C. Evaluation of completeness of operative records in women undergioning gynecologic surgery at Chiang Mai University Hospital. The Journal of Obstetrics and Gynecology. 2011;19:112-117.
Arthur J, Nair R. Increasing the accuracy of operative coding. Ann R Coll Surg Engl. 2004;86:210-212.
Singh R, Chauhan R, Anwar S. Improving the quality of general surgical operation notes in accordance with the Royal College of Surgeons guidelines: A prospective completed audit loop study. Journal of Evaluation in Clinical Practice. 2012;18(3):578–580.
Singh S, Mayahi R. Consent in orthopaedic surgery. Ann R Coll Surg Engl. 2004;86:339–341.
Severn Audit and Research Collaborative in Orthopaedics (SARCO), Assessing the quality of operation notes: A review of 1092 operation notes in 9 UK hospitals Patient Safety in Surgery. 2016;10:5.
Barrit WA, Clark L, Cohen AMM, et al. Improving the quality of procedure-specific operation reports in orthopaedic surgery. Ann R Coll Surg Engl. 2010;92:159– 162.
Sweed TA, Bonajmah AA, Mussa MA, et al. Audit of operation notes in an Orthopaedic unit. Journal of Orthopaedic Surgery. 2014;22(2):218– 220.
Rogers A, Bunting M, Atherstone A. The quality of operative notes at a general surgery unit. S Afr Med J. 2008;98(9):726- 728.
Morgan D, Fisher N, Ahmed A, Alam F. Improving operation notes to meet British Orthopedic Association guidelines. Ann R Coll Surg Eng. 2009;91(3):217- 219.
Khan MUR, Ahmed S, Shamim MS, Azhar M, Rehmam S. Operative notes at surgical units of a tertiary care hospital. Journal of Surgery Pakistan (International). 2010;15(1):57- 59.
Lefter LP, Walker SR, Dewhurst F, Turner RW. An audit of operative notes: Facts and ways to improve. ANZ J Surg. 2008;78:800–802.
Rowlands C, Griffiths SN, Blencowe NS, et al. Surgical ward rounds in England: A trainee-led multi-centre study of current practice. Patient Saf Surg. 2014; 8(11). Available:https://doi.org/10.1186/1754- 9493-8-11
Ghani Y, Thakrar R, Kosuge D, Bates P. Smart electronic Operation notes in surgery: An innovative way to improve patient care. International Journal of Surgery. 2014;12(1):30- 32.
Abstract View: 13 times
PDF Download: 6 times