Audit of operation notes in an orthopaedic unit

To audit operation notes of 50 patients according to the guidelines of the Royal College of Surgeons.

Proforma operation notes of 50 consecutive patients treated in an orthopaedic department were audited by a single reviewer, according to the guidelines of the Royal College of Surgeons in terms of date and time of surgery, name of surgeon, procedure, operative diagnosis, incision details, signature, closure details, tourniquet time, postoperative instructions, complications, prosthesis used, and serial numbers.

There were 45 trauma cases and 5 elective cases. The operating surgeons were consultants (32%), senior registrars (36%), and registrars (32%). 28% and 72% of the operation notes were written by operating surgeons and assistants, respectively. Of the 14 operating surgeons who wrote their own notes, one was a consultant, 6 were senior registrars, and 7 were registrars representing 6%, 33%, and 44% of the respective grades of surgeons. All the notes were handwritten; 20% had illegible parts (all in the description of the operative technique). Documentation was good for date and time of surgery (100%), name of surgeon (100%), procedure (100%), duration of surgery (94%), operative diagnosis (92%), incision details (84%), and signature (84%). Documentation was poor for tourniquet time (32%; pneumatic tourniquet was used in 25 patients, only 8 of whom were documented), closure details (16%), and postoperative instructions (24%).

Documentation of operative details in our department was generally good, except for closure details, tourniquet time, and postoperative instructions.