quality of operation notes audit presentation

7/29/2019 Quality of Operation Notes Audit Presentation

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Audit on the Quality of

Operation Notes

Dr P. Sandhu

Dr P. Lakhtaria

Mrs A. CarmichaelMrs S. Fitter


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Aims & Objectives of the Audit:

To assess the quality of operating notes in

accordance with the guidelines from the

Royal College of Surgeons of England.

To assess if continuity of care can be

established.


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About the Audit:

Type:

A prospective, multi-professional audit to look atthe quality of operation notes within the Trust.

Source:

100 sets of notes were assessed against nationalguidelines from the Royal College of Surgeons of

England and other parameters set locally.


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Analysis:


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Type of Procedure:

88%

12%

Elective Emergency


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Grade of Surgeon:

40%

56%

4%

Cons SPR SHO


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Variables assessed according to

guidelines of the Royal College of

Surgeons of England

(from- Guidelines (2002). Good Surgical Practice,

The Royal College of Surgeons, England, 14-15.)


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Date and Time.

Elective/ Emergency procedure.

Name of operating surgeon and the assistant.

The operative procedure carried out.

The incision.

The operative diagnosis.

The operative findings.

Any problems/ complications.

Any extra procedure performed & reason why it wasperformed

Details of tissue removed, added or altered.

Identification of any prosthesis used, including serial no ofprostheses & other implanted materials.

Details of closure technique.

Post operative care instructions.

Signature.


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Was the Date and Time recorded?

9%

91%

Both Just Date


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Was the Type of Procedure recorded?

100% did not record the type of procedure

(elective / emergency).


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Was the Name of the Operating Surgeon

and the Assistant recorded?

99%

1%

Yes No


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Was the Operative Procedure recorded?

98%

2%

Yes No


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Was the Incision recorded?

95%

5%

Yes No


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Was the Operative Diagnosis recorded?

66%

34%

Yes No


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Were the Operative Findings recorded?

94%

6%

Yes No


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Was there any record of Complications?

10%

90%

Yes No


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Was any extra Procedure performed (i)?

If Yes, was the reason why it was performed recorded (ii)?

9%

91%

Yes No

(i)

89%

11%

Yes No

(ii)


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Were the details of any tissue removed, added

or altered recorded?

79%

21%

Yes No


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Was the identification of any prosthesis used, inc. the serial

number of prostheses and any other implanted materials

recorded?

3%8%

89%

Yes No N/A


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Were the details of the closure technique

recorded?

98%

2%

Yes No


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Were any postoperative care instructions

recorded?

73%

27%

Yes No


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Was a signature recorded?

75%

25%

Yes No


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Other Variables assessed:


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Was a diagram drawn to show the findings?

15%

85%

Yes No


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Was the handwriting legible?

34%

21%

45%

Yes No typed


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Were abbreviations used (i)?

If Yes, were they clear or unclear (ii)?

18%

82%

Yes No

(i)

83%

17%

Clear Unclear

(ii)


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Does the quali ty of notes enable continuity of care?

Our main concern is whether the operation notes

would be able to stand up in a court of law.

The following points were considered whiledetermining if the notes enabled continuity of care.

Poor handwriting/legibility.

Incorrect / missing information, e.g. DOB.

Lack of diagrams


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Inadequate information- e.g.

Procedure explained as routine.

No description of the type of repair done for a hernia.

Two procedures done electively but notes for both

written together & mixed up. Postoperative orders given as discharge when safe.

Use of vague and incomprehensible abbreviations.


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Does the quali ty of operation notes enable

continuity of care?

77%

23%

Yes No


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Recommendations:

Regular revision of guidelines regarding medical

record keeping during weekly meetings.

Use of standard electronic form in the main theatre

(where most of the operation notes are typed).

Changes in the format of the operation note sheet

of the trust ??


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THANK YOU

quality of operation notes audit presentation

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