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Assessing the quality of operation notes: a review of 1092 operation notes in 9 UK hospitals
1Academic Clinical Fellow ST4 Trauma & Orthopaedics, Musculoskeletal Research Unit (MRU), Learning & Research Building, Southmead Hospital, Bristol, BS10 5NB UK.
Insights
Operation note quality varies, impacting patient safety. While legibility and surgeon details were high, critical information like diagnosis and postoperative instructions were often missing, necessitating improved documentation standards.
Area of Science:
- Medical Record Keeping
- Surgical Quality Improvement
- Patient Safety
Background:
- Effective note-keeping is crucial per the General Medical Council.
- Previous studies indicate variable quality in operation notes, potentially compromising patient safety.
- This study assesses operation note quality against national standards.
Purpose of the Study:
- To compare the quality of orthopaedic operation notes against Royal College of Surgeons and British Orthopaedic Association national standards.
- To identify areas of deficiency in operation note documentation that may impact patient safety.
- To inform strategies for improving the quality and completeness of operation notes.
Main Methods:
- Prospective data collection of orthopaedic operation notes over two weeks.
- Inclusion of all elective and trauma operations across nine hospitals.
- Coordination of data collection by regional trainees.
Main Results:
- 1092 operation notes were reviewed.
- High compliance for legibility (98.4%), operating surgeon name (99.3%), and operation title (99.1%).
- Significant deficits in availability on ward (88.8%), anesthetic type (78.6%), diagnosis (73.4%), and findings (80.1%).
- Postoperative antibiotic and venous thromboembolism prophylaxis documentation was inadequate (49.7% and 48.8% respectively).
Conclusions:
- Operation note quality and content were variable across the region.
- Software use in some hospitals correlated with better documentation of basic details.
- Increased awareness of standards and local interventions are recommended to enhance note quality.
Background:
The General Medical Council states that effective note keeping is essential and records should be clear, accurate and legible. However previous studies of operation notes have shown they can be variable in quality and affect patient safety. This study compares the quality of operation notes against the National Standards set by the Royal College of Surgeons of England and the British Orthopaedic Association (BOA) for improving patient safety.
Methods:
Information from Orthopaedic operation notes was collected prospectively over a 2-week period. All elective and trauma operations performed were included and trainees from the region coordinated data collection in 9 hospitals.
Results:
Data from 1092 operation notes was reviewed. A number of important standards were nearly met including legibility (98.4 %), the name of the operating surgeon (99.3 %) and the operation title (99.1 %). However a number of standards were not met and those with potential patient safety implications include availability on the ward (88.8 %), documentation of type of anaesthetic used (78.6 %), diagnosis (73.4 %) and findings (80.1 %). In addition, the postoperative instructions recorded the need for and type of postoperative antibiotics or venous thromboembolism prophylaxis in only 49.7 % and 48.8 % of cases respectively.
Conclusions:
The quality and content of operation notes studied across the region in this period was variable. Use of software programmes in some hospitals for creating operation notes meant that some centres had better results for elements such as date, time and patient identification details. Following this study, greater awareness of the standards combined with additional local measures may improve the quality of operation notes.
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