Assessing the Quality of Operation Notes in a Teaching Hospital

Authors: Huda F*, Kumar N and Verma S

DOI: 10.23880/ghij-16000150

Volume 4, Issue 1

Abstract

Operation notes are very essential written clinical document in the surgical journey of the patient. In spite of being essential, it is left to be written by surgical residents. The Royal College of Surgeons guidance, Good Clinical Practice, with its most recent version in 2014, dictates that surgeons must ensure that all medical records are accurate, comprehensive, legible and contemporaneous. Aim: This study was aimed to compare the quality of operation notes in the Department of General Surgery against the set standards of The Royal College of Surgeons and also to identify the possible shortcomings with a view to suggest practice improving solutions. Materials and Methods: This is a retrospective study done in the Department of General Surgery at All India Institute of Medical Sciences, Rishikesh between 1 st May 2017 to 31 August 2017. Inclusion criteria were all the patients who had undergone major surgery between the study period and whose operation notes was available in the record. Results: Total of 173 operation notes meet the inclusion criteria and were included in the study which were compared with 27 core variables of operation notes as per The Royal College of Surgeons standards. None of the operation notes analyzed in this study completed all the 27 standard variables. Conclusion: Improving the quality of operation notes automatically improves the communication among healthcare workers and helps to prevent errors. We recommend a formal training in writing operation notes to medical graduates and residents to improve the quality of operation notes.

Keywords: Operation Records; Quality of Operation Records

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