Audit of Operative Notes Against Royal College of Surgeons Guidelines in a Tertiary Health Care Surgical Unit in Lahore

Operative notes are important documentation made by the surgical team after a surgical procedure. They outline what happened during the surgery and several aspects of post-operative instructions. The aim of this audit was to compare current practices regarding documentation of these operative notes in a tertiary care hospital in Lahore. The standards used were the recommendations made in the good surgical practice guidelines by the Royal College of Surgeons (RCS) of England in 2014. A prospective closed-loop audit was conducted using a checklist constructed using the RCS guidelines. In the first audit, which was done to analyze current practices, 44 consecutive handwritten operative notes were evaluated. The findings of this initial audit were presented to the surgical team in a local meeting and recommendations were made. Forty-eight consecutive operative notes were then analyzed in the re-audit done after an interval of one month. The findings of the re-audit were presented to the surgical team. An overall 35.7% improvement was noted in the documentation of operative notes after the completion of the audit cycle. Certain parameters analyzed, such as thromboprophylaxis, antibiotic prophylaxis, and anticipated blood loss, were much more frequently documented in the re-audit. In our study, implementation of recommendations such as restructuring of the operative notes pro forma and improving awareness regarding the RCS guidelines significantly improved the quality of operative notes that were being documented. Such audits should be conducted regularly to maintain and improve the standards of documentation in all surgical units.