Title : Audit and re-audit of operation note documentation compliance with the royal college of surgeons and british orthopaedic association guidelines for trauma patients at a North London district general hospital
Abstract:
Aim: This audit aims to improve the documentation of the operation notes at a District General Hospital (DGH) in North London.
Methods: We carried out a closed-loop retrospective audit on trauma operative notes completed at our DGH in North London. The electronic operation notes of 216 trauma patients (1st September–31st December 2020) were analysed for compliance with the Royal College of Surgeons (RCS) and British Orthopaedic Association (BOA) guidelines. The findings were presented at a Clinical Governance meeting with the hospital’s Trauma and Orthopaedic team, and a checklist was posted in the surgeons’ room. Subsequently, the operation notes of 210 trauma patients (1st September–31st December 2021) were re-reviewed to assess documentation compliance improvements.
Results: The re-audit showed improvements in the documentation of incision (85.6% to 97.6%), closure technique (92.1% to 98.6%), antibiotic prophylaxis (57.9% to 86.7%), and postoperative care instructions (92.1% to 99.0%). Documentation of prosthesis used (serial numbers or sizes) improved from 28.2% to 68.1% but remains suboptimal due to nurses recording details in the patient’s paper notes instead of the electronic operation note. Documentation of tourniquet time (46.7%) and anticipated blood loss (6.7%) remains low.
Conclusion: Accurate documentation of operation findings and postoperative plans is essential for continuity of care and medicolegally. This audit shows that simple interventions to raise awareness of the RCS and BOA guidelines can improve documentation. To address the remaining gaps, prompts have been added to the electronic operation note proforma at the hospital. A re-audit will be conducted to assess further improvements.
Audience Take Away Notes
- Our audit underscores the importance of thorough documentation in the operation note, providing education on its importance and what is required of the physicians writing these
This audit reveals that documentation often falls short, with crucial RCS and BOA requirements being overlooked as the attention is often shifted to procedures and findings. Our audit also serves as a tool for trusts to reflect on their own practices, allowing them to make necessary improvements.- Our closed-loop audit highlights how simple interventions, like education and visual prompts, can improve operation note documentation. Other trusts can easily adopt these methods to improve their own standards and patient care.
