Improving the Standard of Orthopaedic Operation Documentation Using Typed Proforma Operation Notes: A Completed Audit Loop

摘要

Introduction The Royal College of Surgeons (RCS) published Good Surgical Practice guidelines in 2008 and revised them in 2014. They outline the basic standard that all surgical operation notes should meet. Objectives To retrospectively audit 57 typed orthopaedic operation notes from St. James’s Hospital in Dublin (from August to November 2015) against the RCS Good Surgical Practice guidelines published in 2014. They were then compared with the department’s previous audit of handwritten notes to complete the audit loop. Materials and methods A total of 57 orthopaedic operation notes were audited by a single reviewer. They were prospectively collected between August and November 2015. All notes were typed on the standard St. James’s Hospital operation note proforma. Results Of the surgeries,?89.5% were emergencies with 77.2% of them being performed by trainees. All of the operation notes were typed and signed by trainees. The procedure name, incision and closure details, tourniquet time (when relevant), and postoperative instructions were documented in 100% of the notes. In total, 80.7% had an operative diagnosis included while only 26.9% of the documentation had prosthesis serial numbers. All of the typed notes were deemed to be legible. Conclusion The use of printed operation notes allows for improved legibility when compared to typed notes. Documentation standards remained very high in the same areas as the handwritten notes and a marked improvement was seen in areas that had been poorly documented.