A Review of Operation Theater Notes in a Tertiary Care Center

Abstract

Documentation plays a very important role in every surgeon’s life. Surgical operation theater notes facilitate postoperative management and are also an important medicolegal document for which world standard guidelines have been established. Few of the standard guidelines for the same are the “Good Surgical Practice,” by the Royal College of Surgeons of England and the National Accreditation Board for Hospitals and Healthcare Providers. This study compares the operative notes from our institution against these standards. Operative notes from all surgical departments from Shanthi Hospital and Research Centre from the time period between June and November 2019 were collected. A total of 625 operative notes have been studied, and the data was tabulated and analyzed. Overall analysis revealed poor documentation of the duration of surgery (0%) and the name of the person documenting the notes (3%). Subgroup analysis revealed that notes from the department of orthopedics had adequate closure details in only one-third of the cases. Diagnosis was missing in about 20% of the cases from the department of urology and orthopedics. The surgical safety checklist was being countersigned by the surgical team in only 4% of the cases. Operative theater notes are important documents, both medically and legally. Reviewing these important documents helps us to compare ourselves with world standards. The deficiencies so detected can be corrected by instituting administrative reforms.