Documentation for Orthopaedic Surgery: An Audit to Ensure Compliance with the Most Recent Guidelines

Abstract

Background: Consistent and thorough documentation in orthopaedic surgery is critical for ensuring quality patient care and protecting the legal interests of surgeons. Adherence to the Royal College of Surgeons (RCS) guidelines is fundamental to achieving this. However, studies have identified a persistent deficiency in compliance with these guidelines across various surgical specialities. Objective: The audit aimed to evaluate the existing compliance of orthopaedic surgical documentation with RCS guidelines at Dr. Ziauddin Hospital and to implement a tool to improve documentation practices. Methods: A closed-loop, two-cycle audit was conducted. The first cycle retrospectively analysed 200 surgical notes from January to July 2023, using a standardized operation sheet to assess compliance with RCS guidelines. Identified deficiencies were addressed by introducing an aide-memoir in all orthopaedic operating rooms. The second cycle prospectively analysed 100 surgical notes from August to October 2023 to evaluate the impact of the intervention. Results: The initial audit revealed a 0% compliance rate in documenting the date, time, and type of surgery (elective or emergency). Following interventions, the second cycle showed significant improvements, with compliance rates rising to 100% for date and time, and to 87% for identifying the surgery type. Additional documentation parameters such as the recording of the assistant's name and incision details also improved, though exact numerical increases were not specified. Conclusion: Introducing an aide-memoir significantly enhanced compliance with RCS surgical documentation guidelines. This simple, effective tool facilitated a remarkable improvement in the quality of operative notes, underscoring the need for regular audits and potential integration of electronic documentation systems.