Assessing the quality of orthopaedic operation notes: an audit cycle

To compare institutional operation notes with the guidelines of the Royal College of Surgeons of England.

The retrospective-prospective, pre-post multi-phase audit was conducted at the Department of Trauma and Orthopaedic, Northwest General Hospital and Research Centre, Peshawar, Pakistan, from August 1 to October 31, 2023. In Phase-I, operation notes were retrospectively reviewed, and the findings were presented in ward meetings with the relevant surgeons. Educational workshops were arranged in Phase-II. In Phase-III, another set of operation notes was evaluated to assess the post-intervention effectiveness across 19 parameters. Data was analysed using SPSS 25.

Of the 128 operation notes reviewed, 64(50%) related to Phase-1. Of them, 45(70%) were typewritten and 19(30%) were handwritten. All the 64(100%) notes showed good compliance for surgeon name, operative procedure, diagnosis, and post-op instructions. The remaining 64(50%) notes related to the post-intervention phase; 50(78%) typewritten and 14(22%) handwritten. There was an average improvement of 40(31.1%), with 17 out of 19 categories showing improvement rate of 115(89.47%). Of the 19 parameters assessed significant progress (p<0.05) was noted in 10(52.6%).

Several deficiencies were identified that were addressed during the intervention, which improved adherence to the guidelines of the Royal College of Surgeons of England.