Audit of post-operative notes in a Nigerian tertiary hospital: A comparison against the Royal College of Surgeons of England’s Good Surgical Practice Guidelines

Abstract

Background: Appropriately filled operation notes are of great importance in all surgical specialties. They serve not only for patient management but also provide information for research, audit, and medico-legal purposes. Objective: This study aimed to assess the quality of operation notes according to the standards set by the Royal College of Surgeons of England (RCSE). Materials and Methods: An initial sample of 30 operation notes was randomly chosen from both the orthopedic and plastic surgery departments of the National Orthopedic Hospital, Enugu, Nigeria and retrospectively audited based on the Good Surgical Practice guidelines published in 2014 by the RCSE. Thereafter, the guideline was printed and pasted on the walls of the operation theater to help residents and serve as a memory aid. Subsequently, a weekly reminder was sent via a text message to the WhatsApp group of the resident doctors. After two months, a re-audit was conducted with another set of 50 operation notes. Results: The initial audit showed a good compliance (ranging from 90% to 100%) with documentation of date, diagnosis, operating surgeon and assistants’ names, operative procedure, detailed post-operative instructions, and signature. In the re-audit phase, no significant improvement was observed in documenting the information that had been poorly documented in the initial audit (P > 0.05). However, a significant difference (P < 0.001) was observed in filling the option for identification of prostheses used and their serial number. Conclusion: Using memory aids in the operation room may not sufficiently improve the documentation of operation notes. There may be need to consider other strategies including the use of electronic devices and the involvement of consultants to ensure compliance.

Keywords

• audit
• documentation
• operation notes