AUDIT OF OPERATIVE NOTES IN AN ORTHOPAEDIC DEPARTMENT.

Dr Hardik Siddharajsinh Pawar

Abstract


PURPOSE:

To audit orthopaedic  operative notes of 53 patients according to the guidelines of the Royal College of Surgeons of England Good Surgical Practice guidelines in February 2014.

METHODS:

Proforma of operative notes of 53 random patients treated in an orthopaedic department were audited retrospectively by a single reviewer, according to the guidelines of the Royal College of Surgeons in terms of date and time of surgery, name of surgeon, procedure, operative diagnosis, incision details, signature, closure details, tourniquet time, postoperative instructions, complications, prosthesis /implant used, and serial numbers.

RESULTS:

There were 53 trauma cases. The operating surgeons were consultants (100%), . 100% of the operation notes were written by operating surgeons.. All the notes were handwritten.All of the operative notes included date and time of surgery, name of surgeon (and any assistants if present), procedure name, and signature. Operative diagnosis was present in (86.79% n=46) of the operation notes. Incision details were included in 0 % of the sheets. Tourniquets were applied in (18.86% n=10) of the procedures with none having a documented tourniquet time (0%). Closure details were documented in   procedure (66.03% n=35). Postoperative instructions were included in 100 % of the operative notes. 53 procedures involved the use of prosthetic/implant; however, only (67.92% n=36) of these had documented or attached serial number adhesives to the operation sheet.

CONCLUSION:

Documentation of operative details in our department was generally good.

Keywords


Opertaive notes, documentation.

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