Improving the Quality of General Surgical Operation Notes According to the Royal College of Surgeons (RCS) Guidelines: A Closed-Loop Audit

BackgroundThorough and precise operative notes play a vital role in patient care, facilitating communication among healthcare teams and serving as essential documents for legal purposes. Poor documentation can jeopardize patient safety and the quality of care provided. The use of standardized guidel...

Full description

Saved in:
Bibliographic Details
Published in:Curēus (Palo Alto, CA) CA), 2023-11, Vol.15 (11), p.e48147-e48147
Main Authors: Toru, Hamza Khan, Aizaz, Muhammad, Orakzai, Abdullah A, Jan, Zaka Ullah, Khattak, Ahmad Ammar, Ahmad, Danyal
Format: Article
Language:English
Subjects:
Audits
Data analysis
Data collection
Documentation
General Surgery
Health care delivery
Health facilities
Hospitals
Medical records
Patients
Surgeons
Surgery
Time management
Citations: Items that this one cites
Items that cite this one
Online Access:Get full text
Tags: Add Tag
No Tags, Be the first to tag this record!
Description
Summary:BackgroundThorough and precise operative notes play a vital role in patient care, facilitating communication among healthcare teams and serving as essential documents for legal purposes. Poor documentation can jeopardize patient safety and the quality of care provided. The use of standardized guidelines, such as those endorsed by recognized surgical organizations, is crucial to ensure consistent and detailed record-keeping. This study aims to assess the alignment of postoperative notes with established guidelines, with the goal of enhancing documentation practices in the healthcare setting.ObjectivesThis study aimed to evaluate the quality and comprehensiveness of postoperative surgical notes and assess their alignment with established guidelines for surgical documentation, specifically focusing on adherence to recognized standards in surgical practice.MethodsThis cross-sectional audit assessed 150 operative notes (79 pre-implementation and 71 post-implementation of the Royal College of Surgeons (RCS) guidelines) in the General Surgery Unit at Khyber Teaching Hospital Peshawar, Pakistan. Data included peri-operative findings, operative diagnosis, team information, operational details, complications, procedures, prosthesis, closure, DVT prophylaxis, time out, postoperative orders, and signatures.ResultsPost-implementation, peri-operative findings were noted in 68 (95.7%) notes, compared to 56 (70.8%) pre-implementation. Operative diagnosis consistently increased from 65 (82.3%) to 69 (97.2%). Post-implementation, operation type, date, and time were consistently included in 67 (94.4%) notes. Complications, additional procedures, and tissue alterations surged to 66 (92.9%), 64 (90.1%), and 60 (84.5%), respectively. Prosthesis and closure techniques were recorded in 65 (91.5%) and 66 (92.9%). Deep vein thrombosis (DVT) prophylaxis and "time out" were documented in 68 (95.8%) notes. Postoperative orders and signatures improved to 70 (98.6%) and 69 (97.2%), respectively.ConclusionOur study revealed the significant positive impact of RCS guideline implementation on operative note documentation. Improvements were noted in essential components such as peri-operative findings, diagnosis, team details, complications, procedures, and more. These enhancements have far-reaching implications, bolstering patient care and ensuring clear communication among healthcare providers, all while serving a vital role in medico-legal matters. By adopting the RCS guidelines, healthca
ISSN:2168-8184
2168-8184
DOI:10.7759/cureus.48147