Audit of Operative Notes and Documentation in a Surgical Unit of Tertiary Health Care Centre Karachi
Keywords:
Clinical audit, Royal College of Surgeons guidelines , Operative notes, Quality improvement , DocumentationAbstract
OBJECTIVE: To assess the quality of operative notes compared to the international standard, recognize flaws and missed information.
METHODOLOGY: This retrospective clinical audit was conducted at Surgical Unit III, Dr Ruth Pfau Civil Hospital, Karachi. Eighty-seven consecutive operation notes were audited from July to September 2024. A checklist was utilized to assess 20 different parameters. The parameters were developed following the 2014 guidelines for Good Surgical Practice set forth by the Royal College of Surgeons of England. The inclusion criteria encompassed all General Surgery patients admitted for elective and emergency surgeries with no exclusions based on the type of procedure performed. The frequency of each parameter was determined. Data analysis was performed using SPSS ver. 22.
RESULTS: Key details, including patient identification, date and time of the procedure, surgeon's name, operative procedure title, and overall legibility, were consistently documented across all records. Nature of procedure, antibiotics prophylaxis and deep venous thrombosis (DVT) prophylaxis were not recorded in any of the operative documents.
CONCLUSION: This audit highlights deficiencies in operative note documentation, particularly regarding DVT prophylaxis, antibiotic prophylaxis, and blood loss recording. Adherence to standards recommended by the Royal College of Surgeons of England and use of standardized documentation templates may improve surgical record quality.
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