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Related Experiment Videos

Improving the Standard of Orthopaedic Operation Documentation Using Typed Proforma Operation Notes: A Completed Audit

Fionn Coughlan1, Prasad Ellanti2, Andrew Moriarty1

  • 1Department of Trauma and Orthopaedics, St James Hospital.

Cureus
|April 14, 2017
PubMed
Summary

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Typed operation notes in orthopaedics show improved legibility and high documentation standards, particularly in emergency surgeries. This audit confirms adherence to Royal College of Surgeons guidelines, enhancing patient care records.

Area of Science:

  • Medical Auditing
  • Surgical Practice Standards
  • Healthcare Documentation

Background:

  • The Royal College of Surgeons (RCS) established Good Surgical Practice guidelines in 2008, revised in 2014.
  • These guidelines define essential standards for all surgical operation notes.

Purpose of the Study:

  • To audit 57 typed orthopaedic operation notes against the 2014 RCS guidelines.
  • To compare typed notes with a previous audit of handwritten notes to assess improvements.

Main Methods:

  • Retrospective audit of 57 typed orthopaedic operation notes from St. James's Hospital, Dublin.
  • Notes were collected between August and November 2015 and typed on a standard hospital proforma.
  • A single reviewer assessed notes against RCS guidelines.
Keywords:
auditnotesoperationorthopaedicproformatyped

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Main Results:

  • 100% documentation for procedure name, incision/closure, tourniquet time, and postoperative instructions.
  • Operative diagnosis documented in 80.7% of notes; prosthesis serial numbers in 26.9%.
  • All typed notes were legible, with 89.5% of surgeries being emergencies.

Conclusions:

  • Typed operation notes offer superior legibility compared to handwritten notes.
  • Documentation standards remain high, with significant improvements in previously under-documented areas.
  • The audit supports the effectiveness of typed notes in meeting surgical practice standards.