Adherence to Guidelines in Orthopaedic Operation Notes: A Quality Improvement Initiative

Orthopaedic operation notes are crucial documents that record the specifics of surgical procedures performed on the musculoskeletal system. They play a vital role in ensuring clear communication between peri-operative and post-operative periods, maintaining patient care and safety, and serving as legal documents. However, studies have consistently shown gaps in the documentation of important parameters.

This study aimed to compare current practices in documenting orthopaedic operation notes with changes in these practices after awareness training and the implementation of an operative notes template, as per the Royal College of Surgeons of England's (RCS) guidelines.

A closed-loop, two-cycle clinical audit was conducted at Dr. Ram Manohar Lohia Institute of Medical Sciences Hospital, Lucknow, India. The first cycle retrospectively analyzed 100 randomly selected surgical notes from December 2024, while the second cycle prospectively analyzed 100 randomly selected surgical notes from March 2025, following a two-month training program and implementation of a new proforma.

The audit showed initial high compliance rates for patient identification (96%) and consultant-in-charge and anaesthetist details (90%), but low rates for all other key parameters, the compliance for a few of which, like surgical details, complications, DVT prophylaxis, and post-operative instructions, was alarmingly low. After targeted efforts, significant improvements were seen, notably in documentation of surgery date/time (91%), emergency/elective procedures (86%), and operative findings (76%). Compliance rates for complications, extra procedures, and post-op care also rose, ranging from 60% to 90%. Overall, documented parameters increased from 35.8% to 90.2%. A statistical analysis comprising a paired-sample t-test and a Z-test for comparing confirmed that the improvement was significant.

The introduction of proper training and implementation of a new proforma based on RCS guidelines led to remarkable improvements in the quality of operative notes. This study highlights the need for regular audits, implementation of standardized templates, and consideration of electronic documentation systems to improve documentation practices.