Audit on the Quality of Operation Notes

Dr P. Sandhu Dr P. Lakhtaria Mrs A. Carmichael Mrs S. Fitter

Aims & Objectives of the Audit:

To assess the quality of operating notes in accordance with the guidelines from the Royal College of Surgeons of England.
To assess if continuity of care can be established.

About the Audit:

Type: A prospective, multi-professional audit to look at the quality of operation notes within the Trust. Source: 100 sets of notes were assessed against national guidelines from the Royal College of Surgeons of England and other parameters set locally.

Analysis:

Type of Procedure:
12%

88%

Elective

Emergency

Grade of Surgeon:
4%

40%

56%

Cons

SPR

SHO

Variables assessed according to guidelines of the Royal College of Surgeons of England

(from- Guidelines (2002). Good Surgical Practice, The Royal College of Surgeons, England, 14-15.)

Date and Time. Elective/ Emergency procedure. Name of operating surgeon and the assistant. The operative procedure carried out. The incision. The operative diagnosis. The operative findings. Any problems/ complications. Any extra procedure performed & reason why it was performed Details of tissue removed, added or altered. Identification of any prosthesis used, including serial no of prostheses & other implanted materials. Details of closure technique. Post operative care instructions. Signature.

Was the Date and Time recorded?

9%

91%

Both

Just Date

Was the Type of Procedure recorded?

100% did not record the type of procedure (elective / emergency).

Was the Name of the Operating Surgeon and the Assistant recorded?
1%

99%

Yes

No

Was the Operative Procedure recorded?

2%

98%

Yes

No

Was the Incision recorded?

5%

95%

Yes

No

Was the Operative Diagnosis recorded?

34%

66%

Yes

No

Were the Operative Findings recorded?

6%

94%

Yes

No

Was there any record of Complications?

10%

90%

Yes

No

Was any extra Procedure performed (i)? If Yes, was the reason why it was performed recorded (ii)?

(i) 9%

(ii) 11%

91%

89%

Yes

No

Yes

No

Were the details of any tissue removed, added or altered recorded?

21%

79%

Yes

No

Was the identification of any prosthesis used, inc. the serial number of prostheses and any other implanted materials recorded?
3% 8%

89%

Yes

No

N/A

Were the details of the closure technique recorded?

2%

98%

Yes

No

Were any postoperative care instructions recorded?

27%

73%

Yes

No

Was a signature recorded?

25%

75%

Yes

No

Other Variables assessed:

Was a diagram drawn to show the findings?

15%

85%

Yes

No

Was the handwriting legible?

34% 45%

21%

Yes

No

typed

Were abbreviations used (i)? If Yes, were they clear or unclear (ii)?
(i) 18%
17% (ii)

82%

83%

Yes

No

Clear

Unclear

Does the quality of notes enable continuity of care?

Our main concern is whether the operation notes would be able to stand up in a court of law. The following points were considered while determining if the notes enabled continuity of care.

Poor handwriting/legibility. Incorrect / missing information, e.g. DOB. Lack of diagrams

Inadequate information- e.g. Procedure explained as routine. No description of the type of repair done for a hernia. Two procedures done electively but notes for both written together & mixed up. Postoperative orders given as discharge when safe. Use of vague and incomprehensible abbreviations.

Does the quality of operation notes enable continuity of care?

23%

77%

Yes

No

Recommendations:

Regular revision of guidelines regarding medical record keeping during weekly meetings. Use of standard electronic form in the main theatre (where most of the operation notes are typed). Changes in the format of the operation note sheet of the trust ??

THANK YOU