Improving the Quality of Operation Notes Without a Proforma: An Audit

An operation note is a medico-legal document and should be accurate and comprehensive. This audit aimed to assess and improve the content of operation notes written in a surgical department at St George's Hospital, London.

This was a two-cycle audit involving retrospective review of operation notes in the Breast Surgery Department at St George's Hospital, London. Sixty-one operation notes from the month of May 2023 were reviewed in the first cycle. Following this, the findings were emailed to clinicians and presented to the department as an intervention to encourage improvement. Verbal reminders were also issued to surgeons in theatre to reinforce the need for detailed operation notes. The audit was repeated after the intervention, reviewing 52 operation notes from the month of December 2023. Data were collated using Excel (StataCorp LLC, College Station, TX, US, USA) and analysed using SPSS (Statistical Package for the Social Sciences; IBM Corp., Armonk, NY, USA). Results are presented in frequency tables.

Post-intervention results demonstrated measurable improvements. Documentation of whether a procedure was emergency or elective increased from 0% in the first cycle to 13.5% in the second cycle. Similarly, recording of anticipated blood loss rose from 0% to 9.6%. Logging of operative diagnosis improved by 19%. There were 12% and 50% improvements in the documentation of details of tissues taken/added/altered and the serial number of implants used, respectively. Although there were modest improvements in documentation of the operating surgeon's name (1.6%), assistant's name (5.5%), procedure name (1.6%), and incision details (4.4%), documentation of operative findings and closure technique decreased by 46.7% and 15.5%, respectively.

This audit shows that intervention through presentation and teaching can lead to improvements in the standard of operation notes.