An analysis of operative notes in major surgeries at a teaching hospital

Abstract

Introduction Operative (OP) note is an important document, which should be recorded immediately after surgery. It should be accurate and in detail, for management of the patient and for legal purposes. In our contest, it's written by surgical trainees and supervised by senior surgeons, which is an important part of surgical training. Materials and methods We have analysed 215 major surgical OP notes including elective and emergency surgeries in general surgical units, Teaching Hospital Jaffna, from 1st of July 2016 to 31st of December 2016. Results All surgeries were performed under general anaesthesia and 83.3 % (n=179) performed by consultants. 90% of OP notes didn't contain time of the surgery, but date of the surgery was mentioned in 82.1% (n=195). Details of surgical team were mentioned in 98.2%, but details of anaesthetic team mentioned in 8.3 %( n=18). Operative diagnosis was missed in 48.8% (n=110) of OP notes. Details of closure technique was not mentioned in 15.5% and none of the notes contained detail of blood loss. Monitoring vital parameters, fluid management and pain management were mentioned 78%, 50%, and 89.9% respectively. Only 6.5% of OP notes were signed by the person who has written. Conclusion and recommendation Operative notes were incomplete in most cases. Several areas were identified for further improvement. Pre-designed surgery specific post-operative forms can be used in operating theatres to improve documentation of op notes.