Vol. 10, Issue 4 (2024)
An audit on assessment of quality of orthopaedic operative notes
Ismail A Pandor and Anshuraj Jagdale
Orthopaedic operative notes are indispensable documents that record intraoperative events, furnish vital information for postoperative care, and serve as the sole legal documentation of surgical procedures. However, the quality of these notes frequently fails to meet established standards, which may result in potential risks to patient care and legal liabilities. This audit was conducted to assess the quality of orthopedic operative notes at the Krishna Institute of Medical Sciences, with the objective of evaluating their compliance with the "Good Surgical Practice" guidelines set forth by the Royal College of Surgeons of England. A retrospective review of 46 operation notes, covering both elective and emergency trauma cases from January to February 2024, was conducted.
The study revealed consistent documentation of core elements such as patient identification, names of surgeons and anaesthetists, type of anaesthesia, and preoperative diagnoses. However, significant gaps were observed in areas crucial to patient safety and medico-legal robustness. Notable deficiencies included the absence of information on intra-operative findings (10%), tissue removal (8%), and closure techniques (0%). Additionally, none of the reviewed notes documented anticipated blood loss, postoperative care plans, or whether the procedure was elective or an emergency. Poor legibility was also a persistent issue, as all notes were handwritten by postgraduate residents with varying levels of experience.
Several opportunities for improvement were highlighted. The findings underscore the need for tailored templates specific to orthopaedic procedures, incorporating headings for critical details such as prosthesis usage, complications, and postoperative care. The introduction of electronic note systems is strongly recommended to enhance legibility, facilitate ease of access, and reduce the risk of misplaced records. Strategies to improve documentation include immediate note-taking post-surgery, the use of audiovisual recordings to aid accuracy, and routine reviews by senior consultants.
This audit serves to illustrate both compliance with key documentation practices and the limitations of a generic pro forma for operative notes. The transition to electronic systems and the incorporation of procedure-specific templates could ensure more comprehensive and accurate records, thereby improving patient care and medico-legal defence. As orthopaedic surgery grows increasingly complex, these measures are vital for fostering a culture of meticulous record-keeping, aiding research, and safeguarding both patient outcomes and professional accountability and this audit also underscores the imperative for the adoption of contemporary documentation practices and the refinement of existing protocols to bridge the identified gaps and standardise the quality of operative notes across orthopaedic departments.
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