Audit of Orthopaedic Surgical Documentation

Area of Science:

• Surgery
• Medical Documentation
• Quality Improvement

Background:

• The Royal College of Surgeons in England established guidelines in 2008 for essential surgical documentation.
• Standardized operation sheets are utilized at St. James's Hospital for all surgical procedures.

Purpose of the Study:

• To retrospectively audit handwritten orthopaedic operative notes against established surgical documentation guidelines.
• To identify areas of strength and weakness in the current documentation practices.

Main Methods:

• A retrospective audit of 63 orthopaedic operative notes over a seven-month period.
• Evaluation of documentation completeness for key elements including date, time, surgeon, procedure, diagnosis, incision, closure, tourniquet time, post-operative instructions, complications, and prosthesis details.

Main Results:

• All notes included date, time, surgeon, procedure, and signature.
• Operative diagnosis and post-operative instructions were often not in the designated location.
• Incision details were documented in 81.7%, prosthesis details in 30%, and tourniquet time in 0% of notes.

Conclusions:

• Documentation completeness is high for basic surgical information.
• Significant improvements are needed in recording tourniquet time, prosthesis details, incision specifics, and the designated location for operative diagnosis and post-operative instructions.