Title : A clinical audit reviewing the operation notes
Abstract:
Introduction: It is essential to have clear communication between the multidisciplinary team when looking after the surgical patients. Events in theatre, including the type of operation, is formally documented in the form of operation notes. Adequate documentation of the procedure, as well as the post-operative instructions, are of paramount significance with regards to perioperative care and patient safety. Additionally, inadequate documentation can lead to poor outcomes for medicolegal disputes. The Royal College of Surgeons have provided guidelines with regards to the documentation of the operation notes and have recommended the domains that should be included in the operation note.
Aim: The aim of this audit was to assess the local practice in the orthopaedic surgery department at Musgrove Park Hospital. It was assessed whether the documentation of the operation notes was in line with the guidance provided the Royal College of Surgeons.
Methods: This was a retrospective review of the operation notes where the operation notes were reviewed over a two-week period in November 2024. The operation notes are documented electronically on EPRO and this was used to review the notes. The domains assessed were date, time, type of procedure, name of the operating surgeon and assistant, anaesthetist, theatre, procedure and incision, diagnosis, findings, details of any tissue removed, antibiotic prophylaxis, closure and VTE prophylaxis. Microsoft Excel was used to record the data on an NHS computer.
Results: Overall, 51 operation notes were reviewed. It was observed that 11 patients (21.6%) had antibiotics but this was not mentioned in the operation note. Additionally, the plan for post-operative VTE prophylaxis was not mentioned for 7 notes (13.7%) and 6 operation notes (11.8%) did not have the name of the anaesthetist. There was also 1 operation note (2%) where the patient was on dual antiplatelet therapy pre-operatively but the operation note did not have clear instructions on when to restart them.
Conclusion and Recommendations: Good documentation of the operation notes was observed in the department overall. It is vital to have clear post-operative instructions, particularly for VTE prophylaxis. It was noted that although most of the operation notes had adequate documentation, there was no standardised template and this could be due to the surgeons having their own templates for common procedures. The findings of this audit were presented locally to the department at the monthly audit meeting and the option of having standardised templates for common orthopaedic procedures was discussed.
