Please use this identifier to cite or link to this item: http://ahro.austin.org.au/austinjspui/handle/1/16949
Title: Quality of handwritten surgical operative notes from surgical trainees: a noteworthy issue
Authors: Nzenza, Tatenda C;Manning, Todd;Ngweso, Simeon;Perera, Marlon;Sengupta, Shomik;Bolton, Damien M;Lawrentschuk, Nathan
Issue Date: 17-Nov-2017
EDate: 2017-11-17
Citation: ANZ Journal of Surgery 2017; online first: 17 November
Abstract: BACKGROUND: Surgical operation notes are crucial for medical record keeping and information flow in continued patient care. In addition to inherent medical implications, the quality of operative notes also has important economic and medico-legal ramifications. Further, well-documented records can also be useful for audit purposes and propagation of research, facilitating the improvement of delivery of care to patients. We aimed to assess the quality of surgical operation notes written by junior doctors and trainees against a set standard, to ascertain whether these standards were met. METHOD: We undertook an audit of Urology and General Surgery operation notes handwritten by junior doctors and surgical trainees in a tertiary teaching hospital over a month period both in 2014 and 2015. Individual operative notes were assessed for quality based on parameters described by the Royal College of Surgeons of England guidelines. RESULTS: Based on the Royal College of Surgeons of England guidelines, a significant proportion of analysed surgical operative notes were incomplete, with information pertaining to the time of surgery, name of anaesthetist and deep vein thrombosis prophylaxis in particular being recorded less than 50% of the time (22.42, 36.36 and 43.03%, respectively).Overall, 80% compliance was achieved in 14/20 standards and 100% compliance was attained in only one standard. CONCLUSIONS: The quality of surgical operation notes written by junior doctors and trainees demonstrated significant deficiencies when compared against a set standard. There is a clear need to educate junior medical staff and to provide systems and ongoing education to improve quality. This would involve leadership from senior staff, ongoing audit and the development of systems that are part of the normal workflow to improve quality and compliance.
URI: http://ahro.austin.org.au/austinjspui/handle/1/16949
DOI: 10.1111/ans.14239
ORCID: 0000-0002-1157-7003
0000-0003-3357-1216
0000-0001-8553-5618
0000-0002-5145-6783
PubMed URL: https://www.ncbi.nlm.nih.gov/pubmed/29148172
Type: Journal Article
Subjects: General surgery
Operation note
Operation report
Urology
Appears in Collections:Journal articles

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