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Royal College of Surgeons Guideline Adherence on Improvement of Operative Notes: A Six-Month Closed Loop Audit

Introduction Every surgical procedure is followed by thorough and descriptive documentation. The Royal College of Surgeons (RCS) introduced official guidelines in 2014 on the proper documentation of operative notes. These guidelines are concise, targeted, and easy to adapt to any surgical specialty....

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Detalles Bibliográficos
Autores principales: Bhatti, Dujanah S, Ahmad, Raheel, Asad, Ayesha
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Cureus 2020
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7273460/
https://www.ncbi.nlm.nih.gov/pubmed/32523827
http://dx.doi.org/10.7759/cureus.7970
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author Bhatti, Dujanah S
Ahmad, Raheel
Asad, Ayesha
author_facet Bhatti, Dujanah S
Ahmad, Raheel
Asad, Ayesha
author_sort Bhatti, Dujanah S
collection PubMed
description Introduction Every surgical procedure is followed by thorough and descriptive documentation. The Royal College of Surgeons (RCS) introduced official guidelines in 2014 on the proper documentation of operative notes. These guidelines are concise, targeted, and easy to adapt to any surgical specialty. Methods and results An audit was conducted from April to September 2019 at District Headquarter Hospital in Rawalpindi, Pakistan. We analyzed 215 operative notes of elective and emergency cases during the first three months (pre-implementation), and after comparing the notes against the RCS orthopedic notes guidelines, we developed a dedicated notes format for use in the second three months (post-implementation). A panel reviewed 235 notes postimplementation for legibility and compliance with the 2014 RCS guideline data. Operative diagnosis was written in 80% pre-implementation notes and 100% of post-implementation notes. Pre-implementation of RCS guidelines, 78% of operative notes included the names of the anesthetist and the operative staff, 88% included assistant names, and 90% included the name of the operating surgeon. Post-implementation, these numbers increased to 92%, 93%, and 99%, respectively. All domains of the guideline were filled, and data point inclusion statistically significantly improved (0.001 < P < 0.005) after the implementation of RCS guidelines. Conclusion Following the RCS guidelines resulted in a significant improvement in all deficient fields in operative notes.
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spelling pubmed-72734602020-06-09 Royal College of Surgeons Guideline Adherence on Improvement of Operative Notes: A Six-Month Closed Loop Audit Bhatti, Dujanah S Ahmad, Raheel Asad, Ayesha Cureus Orthopedics Introduction Every surgical procedure is followed by thorough and descriptive documentation. The Royal College of Surgeons (RCS) introduced official guidelines in 2014 on the proper documentation of operative notes. These guidelines are concise, targeted, and easy to adapt to any surgical specialty. Methods and results An audit was conducted from April to September 2019 at District Headquarter Hospital in Rawalpindi, Pakistan. We analyzed 215 operative notes of elective and emergency cases during the first three months (pre-implementation), and after comparing the notes against the RCS orthopedic notes guidelines, we developed a dedicated notes format for use in the second three months (post-implementation). A panel reviewed 235 notes postimplementation for legibility and compliance with the 2014 RCS guideline data. Operative diagnosis was written in 80% pre-implementation notes and 100% of post-implementation notes. Pre-implementation of RCS guidelines, 78% of operative notes included the names of the anesthetist and the operative staff, 88% included assistant names, and 90% included the name of the operating surgeon. Post-implementation, these numbers increased to 92%, 93%, and 99%, respectively. All domains of the guideline were filled, and data point inclusion statistically significantly improved (0.001 < P < 0.005) after the implementation of RCS guidelines. Conclusion Following the RCS guidelines resulted in a significant improvement in all deficient fields in operative notes. Cureus 2020-05-05 /pmc/articles/PMC7273460/ /pubmed/32523827 http://dx.doi.org/10.7759/cureus.7970 Text en Copyright © 2020, Bhatti et al. http://creativecommons.org/licenses/by/3.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
spellingShingle Orthopedics
Bhatti, Dujanah S
Ahmad, Raheel
Asad, Ayesha
Royal College of Surgeons Guideline Adherence on Improvement of Operative Notes: A Six-Month Closed Loop Audit
title Royal College of Surgeons Guideline Adherence on Improvement of Operative Notes: A Six-Month Closed Loop Audit
title_full Royal College of Surgeons Guideline Adherence on Improvement of Operative Notes: A Six-Month Closed Loop Audit
title_fullStr Royal College of Surgeons Guideline Adherence on Improvement of Operative Notes: A Six-Month Closed Loop Audit
title_full_unstemmed Royal College of Surgeons Guideline Adherence on Improvement of Operative Notes: A Six-Month Closed Loop Audit
title_short Royal College of Surgeons Guideline Adherence on Improvement of Operative Notes: A Six-Month Closed Loop Audit
title_sort royal college of surgeons guideline adherence on improvement of operative notes: a six-month closed loop audit
topic Orthopedics
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7273460/
https://www.ncbi.nlm.nih.gov/pubmed/32523827
http://dx.doi.org/10.7759/cureus.7970
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