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Operation notes in orthopaedics: Beliefs and practices in a developing country
Marlon M Mencia1,2, Diana Persaud3, Kevianne Ragbir3
1Department of Clinical Surgical Sciences, Faculty of Medical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago.
Tropical Doctor
|July 27, 2021
Summary
Orthopaedic surgeons in the Caribbean recognize the importance of operation notes but lack awareness of international standards. A significant number of surgeons admit to writing notes without being scrubbed in, highlighting a critical documentation gap.
Area of Science:
- Surgical Quality Improvement
- Medical Documentation Practices
- Caribbean Healthcare Systems
Background:
- Accurate operation notes are crucial for surgical care quality.
- Electronic health records are limited in the Caribbean due to financial constraints.
- Previous research overlooked the surgeon's role in documentation quality.
Purpose of the Study:
- To assess orthopaedic doctors' knowledge, attitudes, and practices regarding operation notes in the Caribbean.
- To identify culturally unique behaviors impacting surgical documentation.
- To bridge the gap between process-focused studies and the surgeon's direct influence.
Main Methods:
- A 25-item Knowledge, Attitudes, and Practices (KAP) survey was administered to orthopaedic doctors.
- The survey focused on understanding current documentation habits and awareness of standards.
- Data analysis aimed to identify specific challenges and unique behaviors.
Main Results:
- Most doctors acknowledged the importance of operation notes.
- A significant portion of doctors were unaware of international note-keeping recommendations.
- Legibility issues were reported by 92% of respondents.
- A notable 72% of surgeons admitted to writing notes without being scrubbed in for the procedure.
Conclusions:
- Orthopaedic surgeons in the Caribbean value operation notes but need education on international standards.
- The practice of writing notes without being scrubbed in is a concerning and underreported issue requiring further investigation.
- Improving surgical documentation quality necessitates addressing surgeon-specific practices and awareness.
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