Assessing the Quality of Operative Notes

Abstract

Background: Operative notes are an important element of documentation based quality management for clinical practice. Often narrated by surgeons, they are usually penned by hand and are crucial in case of medical and legal consequences. Objective: To assess the operative notes at a tertiary care hospital and compare them to the standards set by Royal College of Surgeons of England. Methods: An observational prospective study carried out in the department of general surgery over a time period of one month from June to July, 2014. Sixty operative notes including general surgery, urology, orthopedics and neurosurgery were included in this study and were assessed according to published guidelines of the Royal College of Surgeons of England. Results: A total of 60 operative notes were reviewed. All of them were handwritten, out of which 40 (66.7%) were written by the operating surgeon. None of the notes mentioned the time of the surgery and the type of surgery and had no diagrams to illustrate the operative findings. Almost all (96.7%) included the patients name and the procedure performed (95%) and only 66.7% mentioned the operative findings. Incomplete post-operative instructions were present in all the notes that were studied. Conclusion: Several areas were highlighted, that lacked essential information in the operative notes, including the time of the procedure, type of surgery, instructions for postoperative care, operative diagnosis, findings, and complications during the procedure indicating that the operative notes were incomplete and inadequate in many respects. Key Words: Operative Notes, Quality Management, Clinical Practice.