Aims and objectives: Accurate documentation of surgical operation notes is crucial as it facilitates the post-operative management of the patients. It also serves as an important medico-legal document for any discrepancies or disputes. The objectives of this study were twofold: to compare operation note documentation against guidelines published in Good Surgical Practice by the Royal College of Surgeons of England (RCS Eng), 2008, and to improve adherence to these guidelines, through educating surgeons and the introduction of theatre aide-memoires.
Method: We prospectively identified 100 general surgical patients operated between February 2010 and July 2010. Equal numbers of upper gastroenterology, colorectal and vascular patients were selected. We audited operation note documentation against the RCS Eng guidelines. Our findings were presented at the trust clinical governance meeting. Areas with deficient documentation were highlighted. In addition to educating surgeons, aide-memoires were subsequently introduced in the operating theatres and our practice was re-audited.
Results: A total of 18 RCS Eng guidelines were identified and audited. The first audit cycle revealed poor areas in documentation of 'emergency/elective procedure' (36%), 'time of operation' (36%), 'date of operation' (87%), 'assistant' (87%) and 'post-operative management' (88%). After educating surgeons and introducing aide-memoires in theatres, the results were re-audited with an equal number of patients. The re-audit demonstrated a clear improvement in four out of five deficient areas with compliance reaching almost up to 100%.
Conclusion: Operation note documentation is of paramount importance, it has medical and legal implications. Educating surgeons and providing aide-memoires in theatres clearly improved documentation of operation notes in compliance with the RCS Eng guidelines.
© 2011 Blackwell Publishing Ltd.