Audit on the Quality of Operation Notes in Otolaryngology: Based on Electronic Template

The operative note is a vital document in the treatment and safety of patients. Detailed recording of operation notes can be quite helpful in research, audit and medico-legal problems. This quality improvement programme was conducted to assess the quality of documentation on an electronic template in comparison to the Royal College of Surgeons (RCS) guidelines. The electronic template used for recording operation notes was compared with RCS guidelines for completeness. A retrospective review of operation notes for all the operations performed by ENT over 1-month period was done. The deficiencies were shared with the department during monthly quality-improvement meetings. A second cycle was carried out in the month of September. The electronic template that is being used in our hospital matches completely with the RCS recommendation. A total of 90 operative records were analysed in the initial audit. The Compliance was 100% in all parameters except five. In the second cycle of audit, compliance was found to be 100% across all parameters, except one-showing considerable improvement. Electronic templates offer easy recording of operation notes without the help of aide memoire, despite which deficiencies do occur. Regular audits are needed to maintain good record-keeping.