Evaluating and Improving the Quality of Surgical Operative Notes at Elobeid Teaching Hospital: A Two-Phase Audit

Surgical operative notes play a critical role in patient care, serving as legal documents and communication tools among healthcare professionals. However, inconsistencies in documentation can compromise patient safety and continuity of care. This study aimed to evaluate and improve the quality of surgical operative notes at Elobeid Teaching Hospital through structured interventions.

A two-phase audit was conducted at the hospital's Department of Surgery, comprising a retrospective phase followed by a prospective phase. In the retrospective phase, 50 operative notes were reviewed to establish a baseline for documentation completeness and accuracy. Following this, an intervention was implemented, which included the introduction of a standardized template based on the Royal College of Surgeons of England (RCSEng) guidelines and training sessions for surgical staff. In the prospective phase, 34 operative notes were analyzed to evaluate the impact of the intervention. The completeness and accuracy of documentation were assessed using predefined parameters in both phases.

In the pre-intervention phase, significant deficiencies were noted in key documentation areas such as anticipated blood loss (0%), deep vein thrombosis (DVT) prophylaxis (2%), and postoperative care instructions (34%). Following the intervention, substantial improvements were observed, with compliance rates reaching 97-100% in several key parameters. The most notable improvements were seen in the documentation of anticipated blood loss (0-97%), prophylactic antibiotic use (20-100%), and DVT prophylaxis (2-82%).

Implementing a standardized documentation template and providing staff training significantly enhanced the quality of surgical operative notes. Continued auditing and reinforcement of best practices are recommended to sustain these improvements and further optimize patient care.