The quality of hand-written operative notes in a surgical unit at Queen Elizabeth Central Hospital (QECH), Malawi: A prospective completed audit loop study

BACKGROUND: Operative note writing is one of the fundamental parts in surgical practice. Accurate documentation is critical, to be of value when used for postoperative care, research, academic purposes and medical legal clarity. Although guidelines guiding surgeons on how to write operative notes exist, deficiencies are noted worldwide. PURPOSE: To assess quality of hand-written operative notes in surgical unit at Queen Elizabeth Central Hospital (QECH) using the RCSEng guidelines as a standard. METHODS: To identify key areas of weaknesses, a sole observer in this study assessed prospectively the quality of operative notes in our setting. The audit loop was completed after adoption of new interventions. RESULTS: Sixty-seven percent of the notes were written by trainees in both audits. Key areas of missing data were on time of performing the operation, urgency, estimated blood loss, complications and extra procedure in the first audit, with a frequency of 0%, 2%, 14%, 38% and 11% respectively. The results improved significantly to 62%, 84%, 62%, 70%and 32% respectively [p<0.05] in the second audit. Half of the postoperative care instructions were inadequate with 29% of the notes partially illegible or completely illegible. CONCLUSION: The study identifies significant deficiencies in our operative note writing. Surgeon's education, use of detailed pro formas with heading prompts and aide memoirs for vital information play a major role in better note completion. The role of electronic health records is highlighted.