Orthopedic Operation Notes: What are we Missing?

Abstract

Background: Accurate legible documentation of operation notes is core element of surgical practice in any Specialty. Complete comprehensive operation notes are also important for maintaining high standard of patient care and for defense in medico legal cases. Aims: Objective of our study was to compare the quality of orthopedic trauma operation notes at our hospital with standard set by the  Royal college of Surgeons , England (RCSE) 2008. Materials and Methods: Retrospective review of 300 Orthopedic trauma surgery notes was carried out for the period 01/1/2017 to 31/12/2017.Additional variables not included in RCSE 2008 guidelines were included in results. The complete data collected was analyzed using SPCC 20 version. Results: The demographic details as well as date, time of surgery, name of surgeon, assistant surgeon, anesthetist, scrub nurse and signature were documented well in nearly all cases. Notes were written by the lead surgeon in 80.6 % cases and 0.5% were consultant notes. Adequate document were; Implant usage in 62.5%, Postoperative instructions 96.6%, Intra operative complications, blood loss, ICD -10 coding were poorly documented while tourniquet time was not documented well. Conclusion: Our study highlighted major deficiencies in some areas with good compliance in other areas. Therefore we suggest to use aide memoire and standard based Performa’s which will improve quality of operation notes and better follow up patient care.