Operation Notes: Is there scope for improvement?
Ashrafun Nessa, MRCS1; David Chadwick, FRCS1
1Nottingham University Hospitals NHS Trust
Operation notes are a crucial aspect of patient documentation for surgical procedures. Poor quality of the operation notes is a cause for concern in the health care system due to the implications for patient safety in the event of a complication and for the quality of patient care. The illegible note can cause difficulty for medical and nursing staff in understanding specific post-operative instructions, cautions, concerns. The RCS has developed guidelines for maintaining and storing medical records including operation notes for surgeons. NUH uses an operation note proforma on a pink booklet (NUH1359S) - “Operation and Anaesthetic Record for Medical or Surgical Investigation, Treatment or Operation”.
This study compares the quality of operation notes against the National Standards set by the Royal College of Surgeons of England and rates of completion of operation notes proforma in our current practice in General Surgery, Upper GI Surgery and Endocrine Surgery in Nottingham University Hospital.
(1) Documentation against RCS standards;
(2) The impact of a standardized operative proforma.
MATERIAL AND METHOD
50 operation notes were randomly selected, relating to operations performed in Upper GI, General, and Endocrine Surgery, and were audited against the RCS recommendations between December 2017 and January 2018.
Data collection was done by junior doctors prospectively on a data collection proforma and then data transferred to MS Excel for analysis.
8 of the 20 standards had 100% compliance and 11 of the 20 standards had >90% compliance.
All the notes included patient details, dates, name of surgeon and assistant, the name of the procedure and operative findings, postoperative instruction. The proforma provided aid memoir for these to record.
Current practice showed 100% record of Assistant name despite the absence of aid in the proforma.
Details most frequently omitted was time, whether elective or emergency surgery. Operative diagnosis, Problems, complication and whether any extra procedure performed were not very evident in the notes.
8 out of 50 records were typed and had improved legibility and the disparity between typed and handwritten notes was evident. Details of closure technique, postoperative instruction and signature were included in 92%, 100%, 94% notes respectively. Details of whether elective /emergency, the anesthetic name was included in 100% of typed and 0 % of handwritten notes respectively.
Local operation note is part of a booklet which combines the nursing/anaesthetic/post-op recovery records and, the data were derived from the ‘operation note’ part alone. Hence, compliance may have been underestimated for some features, such as time, whether elective or emergency surgery as the information might have been recorded elsewhere in the whole document.
The data collection tool used in this audit has not included Name of the theatre anesthetist Anticipated blood loss, Antibiotic prophylaxis, DVT prophylaxis, which are included in the recent Good Surgical Practice 2014 guidance. These data are also available in the booklet.
The apparently low compliance of recording of certain data items, such as Identification Number of a Prosthesis or Intra-operative Complications, additional Procedures, might be due to the fact that these do not apply necessarily to all procedures. If a prosthesis was not used, the operation note might not necessarily record this as ‘not applicable’, for instance. Taking this into account, compliance was estimated to be close to 100% for these data fields’.
So it needs to be differentiated whether these criteria are ‘not applicable’ or ‘failure to record’ and is potentially important when these guidelines are used by junior health care providers or non-clinical audit stuff.
The other shortcoming was legibility (74%), which was improved in typed notes. The typed notes included all the criteria of RCS prescription and were printed on white paper then attached to the pink booklet.
Typed operation notes showed improved documentation compared to handwritten records, hence methods which increase the uptake of typed operation notes, coupled with a greater awareness of the RCS standards might also be helpful.
We plan a program of clinician education, amendment of the proforma to include the commonly missed elements of data.
Overall, compliance with the RCS national standard for operating notes was high, possibly due to the existence of an established local proforma. There is scope for further improvement, which might be achieved by modifying the existing proforma and introduction of typed operation note when NUH goes paperless.
1.The Royal College of Surgeons of England. Guidelines for clinicians on medical records, 1994. Available at: https://www.rcseng.ac.uk/publications/docs/med_re cords.html.
2.The Royal College of Surgeons of England. Good surgical practice, 2008. https://www.rcseng.ac.uk/publications/docs/goodsurgical-practice-1