F. Mannan1, R. Gill1, A. R. Alvi1 1The Aga Khan University Hospital,General Surgery,Karachi, SINDH, Pakistan
Introduction:
Operative notes are one of the most essential components of good surgical practice. It forms an important record of intervention performed on the patient with its medicolegal implications.Proper documentation of these notes ensures the patient continuity of care is maintained and quality of care is enhanced which may also have an impact on follow up and future management of the patient. Royal College of Surgeons has issued guidelines to standardize operative note documentation. We aimed to determine the frequency of adherence of laparoscopic appendectomy operative notes with the RCS guidelines at our tertiary care centre.
Methods:
The Study was conducted at the Aga Khan University hospital Karachi over a six month period between January and June 2018 after seeking approval from the Ethics Review Committee. It was a crossectional study and data was analysed by using SPSS version 21. Descriptive analysis of continuous variables along with overall score of operative notes was deduced to assess the frequency of adequate practice compared to the RCS guidelines. Stratified analysis was done for effect modifiers and p value of < 0.05 was taken as statistically significant.
Results:
A total of 74 operative notes relating to laparoscopic appendectomy were reviewed during the study period. Majority of the cases were carried out as inpatient procedures (91.9%). The average age of resident writing the notes was 27 year +/-1.97. Forty Six percent notes were written by year one residents. Female residents contributed to around 55 percent of operative notes. Twenty four percent operative notes showed adequacy of practice in concordance with RCS guidelines. The most lacking component in operative notes was mentioning of the operative time, port sites, intra operative complications and details of specimen removed. Stratified analysis of operative notes did not reveal any association between age, gender and level of training of residents to affect the adequacy of operative note documentation.
Conclusion:
There is a huge gap in documentation of operative notes compared to the Royal College of Surgeons guidelines for good medical practice. Only a quarter of our documentation fulfils the criteria for adequacy of practice. Residents need to be educated and familiarized with these guidelines to improve documentation of operative procedures. Strategies need to be formulated and tested to improve our performance.