Audit of operation notes in an orthopaedic unit

Area of Science:

• Orthopaedic Surgery
• Surgical Documentation
• Quality Improvement

Background:

• Accurate operation notes are crucial for patient safety and continuity of care.
• The Royal College of Surgeons provides guidelines for comprehensive surgical documentation.

Purpose of the Study:

• To audit the quality of operation notes in an orthopaedic department.
• To assess compliance with Royal College of Surgeons guidelines.

Main Methods:

• A single reviewer audited proforma operation notes of 50 consecutive orthopaedic patients.
• The audit assessed documentation of 14 key elements, including date/time, surgeon, procedure, diagnosis, incision, signature, closure, tourniquet time, postoperative instructions, complications, and prosthesis details.

Main Results:

• Documentation was excellent for date/time (100%), surgeon name (100%), and procedure (100%).
• Areas with poor documentation included tourniquet time (32%), closure details (16%), and postoperative instructions (24%).
• 20% of handwritten notes had illegible parts, primarily in the operative technique description.

Conclusions:

• Overall surgical note documentation in the audited department was satisfactory.
• Specific areas requiring improvement include closure details, tourniquet time, and postoperative instructions to enhance surgical record quality.