Assessing the Quality of Orthopaedic Operation Notes in Accordance With the Royal College of Surgeons Guidelines: An Audit Cycle

Introduction Accurate and detailed operation notes are of great importance in all surgical specialties not only for patient care but also for providing information for research, audit and medico-legal purposes. In this audit cycle, we assessed the quality of operation notes against the standards set by the Royal College of Surgeons of England. Methodology A sample of 59 operation notes was randomly selected from the orthopaedics department at Ribat University Hospital and retrospectively audited by three reviewers according to the Royal College of Surgeons of England Good Surgical Practice guidelines released in 2014. A memory aid was then placed in the operation theatre, emphasising mainly the points with poor compliance in the audit. A re-audit was then performed for another 59 operation notes. Results During the first audit, 59 elective operation notes were reviewed, and there was good compliance with date documentation (86%), diagnosis (85%), operating surgeon (90%), assistants’ names (86%), operative procedure (98%), detailed post-operative instructions (98%) and the signature (75%). In the re-audit phase, another 59 operative notes were reviewed; four of them were emergency operations. An improvement was noted in documenting the information that had been poorly documented in the first audit. In the first audit, 20% of the operation notes were written by the operating surgeon, while only 14% were written by the operating surgeon in the re-audit. Conclusion Our implementation of a memory aid in the operation theatre helped to improve the reporting of some of the criteria; however, some components of the operation notes remained poorly filled in.