Audit of the Operation Note of the Orthopaedic Surgery Department of Federal Medical Center Birnin Kudu
Terver Josiah Ngibo, Hamzah Ibrahim JattoAbstract
Background:
Comprehensive and accurate operation notes are crucial for effective communication, continuity of care and medico-legal documentation in surgical practice. This audit aimed to evaluate and improve the quality of orthopaedic surgery operation notes.
Methods:
A retrospective audit was conducted using the Royal College of Surgeons of England (RCSE) guidelines to assess the completeness and quality of 60 randomly selected handwritten orthopaedic surgery operation notes from a three-month period. Key documentation parameters were evaluated, and targeted interventions were implemented. A follow-up audit was conducted with another set of 60 operation notes to assess the impact of these interventions.
Results:
The initial audit revealed a mean compliance of 47.44%, with significant deficiencies in several key documentation parameters. Following interventions, including education and redesign of operation note templates, the follow-up audit demonstrated a mean compliance of 94.44%. Notable improvements were observed across all parameters, with compliance rates increasing from 0% to 100% for some critical elements.
Conclusion:
The implementation of targeted interventions based on the RCSE guidelines significantly improved the quality and completeness of orthopaedic surgery operation notes. Regular audits and continuous education are essential for maintaining high standards of surgical documentation, ultimately enhancing patient care and surgical outcomes.