Abstract
Studies of operation notes have shown they can vary in quality and affect patient safety. This audit compares the quality of operation notes against standards set by the Royal College of Surgeons of England and the British Orthopaedic Association.
Information from operation notes was collected prospectively over a two-week period. All operations performed were included and trainees from the region coordinated data collection in 9 hospitals.
Data from 1091 operation notes was reviewed. A number of standards were nearly met including legibility (98.4%), the name of operating surgeon (99.3%) and operation title (99.1%). However a number of standards were not met and those with potential patient safety implications include availability on the ward (88.8%), documentation of type of anaesthetic used (78.6%), diagnosis (73.4%) and findings (80.1%). In addition, the postoperative instructions recorded the need for and type of postoperative antibiotics or venous thromboembolism prophylaxis in only 49.7% and 48.8% of cases respectively.
The quality of operation notes studied across the region in this period was variable. Software programmes meant some hospitals had better results for date, time and patient identification details. Following this study, awareness of the standards combined with additional local measures may improve the quality of operation notes.
