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Audit of Quality of Operative Notes in a Paediatric Surgical Unit - Abstract

Ramnik Patel, Govind V. Murthi



Purpose: To ascertain the quality of written operation notes in our Unit, with regard to compliance and adherence to existing Guidelines published by Royal College of Surgeons of England in “Good Surgical Practice” and to enhance the professionalism; to identify the areas for improvement and resources required to achieve these standards.

Materials and Methods: In this retrospective audit, case-notes of 50 patients operated upon for eight common paediatric surgical conditions by 6 consultants were selected randomly. The written operation notes from these case-notes were scrutinized and reviewed for the quality, accuracy and details for presence/absence/legibility of selected criteria from the guideline as gold standard. The eight common conditions selected included circumcision, inguinal herniotomy, appendectomy, pyloromyotomy, laparoscopic procedure, endoscopic procedure, orchidopexy, and laparotomy.

Results: Whilst overall quality of documentation appears to be reasonable, no single case of 100% accuracy has been found. Absent (22%) and/or illegible (6%) signatures is of concern, whether procedure “satisfactory/complicated” not always evident – positive wording is necessary to emphasize the outcome.

Conclusions: Sub-optimal quality of operation notes can adversely affect continuity of patient care and is a medico-legal hazard. Simple compliance to the attached operation sheets may significantly improve the quality of the notes. Use of amended and revised operation note template, typed operation notes or an introduction of computerised database system with digital images could help improve standards.

Key words: accuracy, audit, clinical governance, good practice, legibility, medico-legal, operation note, quality control, standards, surgery


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