Operative notes in orthopaedic surgical care in nigeria
Authors:Int J Biol Med Res. 2011; 2(3): 668-670
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Objective: To determine the quality of operative notes in orthopaedic surgery procedures.
Background: As University of Abuja Teaching Hospital Gwagwalada transforms from a specialist hospital to a tertiary institution there is the need to improve our practice to conform to standard practice and develop a centre for research and teaching. Our hypothesis is that the present method of operative note documentation is inadequate and that the quality of note written by operating surgeons would be better compare to that of the assistants.
Materials and Methods: An audit of 120 consecutive orthopaedic surgery operation notes was assessed using Royal College of Surgeons of England (RCSE) guideline. The quality of our notes was compared to the established standard; also the quality of notes by the operating surgeons was compared to his assistants. The data was analyzed with SPSS 17.0.
Results: Of the 120 operative notes reviewed, 86(71.7%) were written by the assistants, and 34(28.3%) by the operating surgeons. The majority of the note did not conform to that in the RCSE guideline. The quality of documented notes by the operating surgeon was higher in parameter such as the surgeonís name, procedure performed, type of incision, operative findings, closure technique, suture used, post operative instructions, post operative fluid management, thrombo-prophylaxis and nurse instruction compared to that taken by his assistants and these were statistically significant (p<0.001).
Conclusion: This study identifies areas of improvements in our operative notes. Introduction of proforma and supervision of the assistants by the operating surgeons would improve documentation following surgery.