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Audit of Quality of Operative Notes in a Paediatric Surgical Unit

Ramnik Patel, Govind V. Murthi
Department of Paediatric Surgery, Sheffield Children’s Hospital, Western Bank Sheffield, United Kingdom

 

Abstract

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

 

Correspondence

Govind V Murthi
Department of Paediatric Surgery
Sheffield Children’s Hospital NHS Foundation Trust, Western Bank
Sheffield S10 2TH United Kingdom
Phone: 0114 2717515; Fax: 00441142260543; Mobile: 00447751829696
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Introduction

Operation notes are an important part of medical records for clinical, academic, research and medico-legal reasons. Providing an appropriate operation note is not only good practice [1], it is a professional [2] and legal requirement. Operation notes should be legible, accompany the patient and sufficiently detailed to enable continuity of care by another doctor [1].

In the court of law, what is not written down may be perceived as if it has never happened, while poorly written or illegible notes including the use of confusing abbreviations are common sources of weakness in a surgeon’s defence. This is of increasing importance due to changes in the working practices of junior staff in the UK now due to ward- (rather than firm-) based teams and European Working Time Directive with shorter shifts and more handovers. The increasing emphasis on audit and management responsibilities led us to investigate the state of the operation notes in our unit.

Patients and Methods

This retrospective audit was carried out after approval and permission of our hospital standing ethical committee. 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 studied and marked for presence/absence/ legibility of selected criteria from the Royal College of Surgeons’ (RCS) Guidelines [1].

Information required by the RCS guidelines was broken down to individual data points and put onto a checklist. The criteria included patient’s name, hospital number, date of birth; date and time, elective/emergency procedure, operating surgeon and assistant, consultant, diagnosis, procedure, incision, operative findings, procedure details, prostheses, closure/sutures, immediate post-operative instructions and surgeon’s signature. The data recorded were compared with those required by the RCS good surgical practice guideline criteria. Added to this check list were several other data points which are not required by the guidelines but which were clinically relevant and may be present in the note.

Results

We have collected and analysed the standard of documentation of operation notes. The results are presented in Table 1. All criteria were evaluated regarding information that should be documented and the absence and/or illegibility of this important information was documented. Deficiencies were revealed in all criteria selected. None of the notes were fully complaint with the gold standard guidelines.

Table 1. Various criteria selected and their results; some of the criteria were applicable in limited numbers and they are shown in the brackets with each criterion.

Recorded

Yes (%)

No (%)

Illegible (%)

Patients name recorded?

98

0

2

Patients date of birth recorded

90

4

6

Patients hospital number recorded?

78

20

2

Date recorded?

98

0

2

Time recorded?

6

94

0

Elective/emergency procedurrecorded?

2

98

0

Operative procedurrecorded?

94

0

6

Name of operating surgeon recorded?

94

0

6

Name of operating  assistants recorded?

84

12

4

Position of the patient (if relevant) recorded? (n=11)

58

25

17

Incision recorded? (n=47)

96

0

4

Findings recorded?

90

4

6

Anyproblems/complications recorded?

46

48

6

Reason for above given?

79

0

21

Details of any tissues removed/added/altered recorded?(n=44)

41

52

7

Identification of any implanted material used recorded?(n=10)

70

0

30

Any extra procedurperformed? (n=14)

22

72

6

Details of closure technique recorded? (n=46)

91

2

7

Type of dressings used (if relevant) recorded? (n=46)

72

22

6

Type of suture material used (if relevant) recorded (n=46)

89

4

7

Post-operative instructions given?

88

6

6

Is there a signature?

72

22

6

 

Patient’s name (98%) and date of birth (90%) is the commonest identifier’s used while the hospital number has been used in 78%. Although the patient’s name was entered in all cases, it was illegible in 2%. Date of the procedure is recorded in 98% while the time (6 %) and the type (2%) of the procedure (emergency/ elective) have been missed in majority of cases. Name of the procedure and surgeon was recorded in 94% and was illegible in 6%. The details of the assistant were missing in 12%.

Position of the patient was recorded in 58%, absent in 25%b and illegible in 17%. Incision was recorded in all but was illegible in 6%.Findings were not recorded in 6% and illegible in 6%. Any difficulty, options and complications were mentioned in 46%, absent in 48% and illegible in 6%. The reason for these was given but was illegible in 21%.

Details of the tissues removed (e.g. foreskin, appendix) was missing in 52%. Implanted material details were added but were illegible in 30%.

Extra procedures performed were not detailed in 72%. Details of the closure technique were recorded in 91% and the type of the dressing documented in 72%. Suture material was recorded in 89% and postoperative instructions given clearly in 88%. The signature was missing in 22%. This study revealed that some of the important vital elements of record were missing and there were use of non-standardized unacceptable abbreviations as well.

Discussion

Comprehensive, clear, concise, complete, correct and consistent documentation of a surgical procedure is an essential component of good medical practice. Historically, operative notes have been handwritten, causing several problems: use of abbreviations [3], poor legibility [4], lack of description of the procedure [5]. These problems are faced in all surgical specialties, but the standard of operation notes in some of the surgical specialities have been notoriously poor and have come in for particular criticism.

Legible notes accurately recording the necessary information should be available for each operation preferably by the operating surgeon. If the person writing the operation note is unaware of the all the information required, substandard record will be the likely result.

Additional Speciality Criteria includes tourniquet time and pressure, local anaesthetic, antibiotic/deep vein thrombosis prophylaxis, postoperative instructions: antibiotics, check x-ray, weight bearing/mobilisation, suture removal/ wound care, drain/catheter removal, outpatient attendance [6, 7].

Previous audits of the quality of general surgical operation notes in district general hospitals have shown variable results. Several solutions to the problem have been tried: aide-memoire in theatre [3], proforma attached to notes [8], operation notes produced by word processor using predesigned templates [9], and the introduction of a computer- generated operation note as part of the computer clinical information system [10].

NHS Care Records Service allow clinicians to access linked records from every NHS organisation used by a patient in both primary and secondary care with details of all investigations and treatment, including operation records [10].

The value of proforma in the production of high standard operation notes has been demonstrated in various surgical specialities. The introduction of computer-generated operation notes has improved their quality in terms of compliance with Royal College guidelines and is compatible with the wider aims of NHS Care Records Service.

We conclude that a consistent compliance to the good surgical practice recommended by the Royal College of Surgeons can significantly improve the quality of the operation notes, continuity of the patient care and potentially avoid medico-legal problems. There is an urgent need for the revision and modification of the most of the operation note templates used by the hospitals as well as introduction of computer database in operation note with appropriate training of the staff. A significant induction of resources is required to redress the situation. Use of digital photographic images to supplement written records has been used to give more complete account of a patient’s treatment [11]. The results of the current audit have been used to implement change in the practice and the audit cycle will be completed by repeat follow up study.

 

 

References

1. Good Surgical Practice - Professional Standards and Regulation. 2008. published by RCSENG http://www.rcseng.ac.uk/publications/docs/good-surgical-practice-1

2. General Medical Council. Good Medical Practice. London: General Medical Council, 2006.

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4. Mathew J, Baylis C, Saklani AP et al. Quality of operative notes in a district general hospital: a time for change? The Internet Journal of Surgery 2003; 5:1

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6. British Orthopaedic Association. Knee Replacement - a Guide to Good Practice. London: British Orthopaedic Association, British Association for Surgery of the Knee, 1999.

7. British Orthopaedic Association. Primary Total Hip Replacement: A Guide to Good Practice. London: British Orthopaedic Association, 2006.

8. Al Hussainy H, Ali F, Jones S et al. Improving the standard of operation notes in orthopaedic and trauma surgery: the value of a proforma. Injury 2004; 35: 1102-6.

9. O’Bichere A and Sellu D. The quality of operation notes: can simple word processors help? Ann R Coll Surg Eng (Suppl) 1997; 79: 204-8.

10. NHS Connecting for Health. Guidance for the NHS about Accessing Patient Information in New and Different Ways and What this Means for Patient Confidentiality. London: NHS Connecting for Health, 2006.

11. Haywood RM, Heaton M, McCullough TA et al: Operation notes illustrated with digital images. Sarcoma 2005, 9: 21-24.