Audit of orthopaedic surgery operation notes at Chris Hani Baragwanath academic hospital
Date
2017
Authors
Chauke, Nyiko Zakaria
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Abstract
Introduction:
The medical record is critical for the documentation of the patient’s current and
possible future health status, as well as for communication between the healthcare
professional and other service providers, statutory and regulatory bodies. Statutory
and /or regulatory bodies and medical councils around the world emphasises the
importance of accurate, adequate and comprehensive medical records. The operative
notes are the official documentation of a surgical operation or procedure and serves
as a key form of surgical communication between healthcare professionals and other
healthcare service providers. Surgical operative notes also serve other important
functions related to medical cost billing, quality assurance, medical education,
research purposes and medico-legal issues. There is no consensus among surgical
disciples on the required standard operative notes or acceptable operative notes
documentation. The royal college of surgeons of England (RCSE) has published
guidelines on the operative notes documentation that are widely accepted in the
United Kingdom and supported by the British Orthopaedic Association.
Aim:
The aim of the study was to assess the completeness of the clinical records for the
Orthopaedic surgery operative notes to:
Evaluate the completeness of operative notes with respect to the RCSE 2008
guidelines
Determine the essential information that was omitted from operative notes
Methodology:
The study was a retrospective, descriptive single centre study conducted at Chris Hani
Baragwanath Academic Hospital between 01 August 2013 and 30 November 2013.
Clinical records were evaluated specifically for the orthopaedic surgery operative
notes details and compared to the guidelines based on the RCSE 2008. The data were
collected from 25 % of all orthopaedic surgical procedures performed in the year 2013.
Results:
A total of 400 clinical records were available for the review of orthopaedic surgery
operative notes. All operative notes were hand-written and no separate operative
notes proforma or template was used for operative notes documentation; all operative
notes were written in the daily ward round progress sheet. No aide-memoire was
available or used to assist the surgeon and or assistant with writing of the operative
notes. The study revealed poor documentation of essential information in the operative
notes with only 0.25 % meeting all the parameters as per RCSE guidelines. Up to 93.3
% of the operative notes were written by the medical officers and registrars, whereas
4.3 % of the operative notes were written by the consultants. In addition, 56.8 % were
missing 5 – 9 parameters, and of the additional parameters included in the study 50.6
% were missing 5 – 9 parameters and 48.5 % missing 10 or more parameters. Poor
documentation was found with regards to details of prophylactic antibiotics missing in
90.8 % of all operative notes, tourniquet usage missing in 58.4 %, operative findings
not mentioned in 55.8 %, identification of prosthetic material or implants missing in
77.0 % and use of blood and or blood products missing in 95.5 %.
Discussion:
The study represents 25 % of all orthopaedic surgery operations performed in the year
2013. The findings of the study are consistent with the previous published studies
reporting poor operative notes documentation without the use of aide-memoire,
proformas, computerised or paper based templates and procedure specific proforma
following acceptable guidelines.
Conclusions:
The findings of this study confirm poor documentation and significant deficiency of
essential parameters in the operative notes that is required for the patient safety and
highlight lack of consensus on the essential parameters required for a complete
operative notes details. Future research using the orthopaedic operative notes
template and/or proformas is recommended to assess completeness of the operative
notes documentation.
Description
A research report submitted to the Faculty of Health Sciences, University of
the Witwatersrand, Johannesburg, in partial fulfilment of the requirements for
the degree of Master of Medicine in the branch of Orthopaedic surgery