Enhancing Neurosurgical Practice through Adherence to Operative Note Guidelines: An Audit

Background Infection in orthopedic surgery is one of the most dreaded complications. It is associated with prolonged morbidity, disability, and increased mortality. One of the cornerstones of the prevention of infections is antibioticprophylaxis. This study assessed the practice of antibiotic prophylaxis in arthroplasty surgeries in our local hospital. Methods One hundred and seventy-one elective joint replacement patients were retrospectively analyzed for documentation of antibiotic plan in postoperative instruction, choice of antibiotic, dose, anddosage. Compliance with the dosage (duration and frequency) of antibiotic prophylaxis was compared among patients who underwent different operations, among patients whose operation notes had antibiotics plans, and among those patients whose operation notes lacked this information. Results Ninety-six females and 75 males with a mean age of 71.4±9.8 years who underwent hip replacement, knee replacement, or shoulder replacement were included in this study. Preoperative and postoperative antibiotics were received by 100% and 94.7% of patients, respectively. In 19.3%, there was no instruction about postoperative antibiotics while 4% missed at least one postoperative dose. The dosage of postoperative prophylactic antibiotics was variable as 26.3% of the patients experienced delayed administration of doses. Not having intravenous access, failure to prescribe antibiotics, and prescribing antibiotics in the "once only" rather than "regular medication" section of the medication chart were the reasons for improper timing of antibiotic doses. Observing surgical safety checklist was effective in ensuring preoperative antibiotic administration, whereasfailing to document antibiotic plan in operation note was associated with poor compliance with postoperative dosage. Interprofessional participation is crucial to compliance with antibioticprophylaxis practice. Conclusion This study identified key areas for improvement in our antibiotics prophylaxis practice. It resulted in implementing strategies to improve staff's awareness about the importance of timely administration of prophylactic antibiotics and proper documentation by all team members.

Background:Operation note documentation captures the key findings and subtle elements of a surgical strategy and is crucial for patient safety. Poor operation note documentation can negatively influence postoperative patient care. This study aimed to assess manual operation note documentation practice.Methods:An institutional-based, cross-sectional study was conducted from 30 March to 30 April 2022, on 240 operation notes of patient data. Data were entered and analyzed by SPSS version 20. According to the RCSE, the Royal College of Surgeons of England, the practice of operation note documentation was rated excellent for each variable when it met 100%, good if it met more than 50%, and poor if it met less than 50% of the operation notes of patient data.Results:All operation notes (n=240) were handwritten. The practice of manual operation note documentation was deemed excellent in two (7.69%), good in 18 (69.2%), and poor in six (23.1%). Residents wrote 84.2% of the operation notes and surgeons and assistants were identified in greater than 94% of the notes, while anesthesia team members were identified in 90.8%. Estimated blood loss was documented in 4.2% of the notes, and the closure technique was described in 64.2%. The operation note templates did not include antibiotic prophylaxis, runner nurse name, or gauze and instrument counts. The urgency of the surgery and time of documentation had a negative relationship, and the seniority of the operation note writer had a positive relationship with manual operative note documentation practice.Conclusions and recommendations:Compared to the standard, all operation note documentation was incomplete and below the standard. We recommend that this comprehensive and specialized hospital administrator implement a new format for operation notes that incorporates RCSE requirements.

Aim Accurate and comprehensive operation notes are crucial for patient care, quality assurance and medico-legal purposes. Laparoscopic cholecystectomy (LC) is one of the most common procedures in General Surgery, either in an Elective or Emergency setting. Therefore, there is a need for an accurate and standard way to document the operation notes for a safe immediate and late post-operative care, including follow-up. The LaCON project aims to evaluate and improve the quality of the operation notes. Method A retrospective review of operation notes of LCs performed at our institution between August-November 2022. Electronic notes were assessed against the Royal College of Surgeons’ Good Surgical Practice standard, consisting of 18 items. Results A total of 80 operation notes were reviewed. There was 100% compliance in surgeon’s name, operation procedure, incision, port sites, and closure technique. Other high-scoring items were indication (98%), operative findings (98%), operation date (91%) and assistant’s name (90%). Among the lowest-scoring items were detailed postoperative instructions (46%), designation as elective or emergency (38%), operative diagnosis (16%) and estimated blood loss (EBL) (8%). Conclusions We identified several areas for improvement in LC operation notes, such as a detailed and robust post-operative plan, a precise intraoperative diagnosis and information about EBL. The LaCON project highlighted the need to implement an electronic evidence-based proforma to standardise notes. This proforma will be accessible through a secure online app, in line with the local Hospital policies, and will allow accurate and contemporaneous record keeping and efficient extraction of operative data for analysis.

Introduction Meticulous operation note documentation is essential for seamless, safe continuity of care in postoperative surgical patients. This study evaluated the standard of emergency operation note documentation at a district general hospital, when compared to the Royal College of Surgeons of England (RCSEng) guidelines and assessed the impact of a new operation note proforma. Method A retrospective review of 50 emergency operation notes was conducted between December 2019 and March 2020 and compared to RCSEng guidelines. Initial findings were presented at a local clinical governance meeting and a new electronic operation note was introduced. A further 50 emergency operation notes using the new proforma were analysed between August 2020 and December 2020. Results RCSEng mentions 19 main points that all operation notes must include. A total of 100 operation notes were reviewed and each given a score out of 19. Intervention of the new proforma showed significant improvement to the average score (15.64 vs 17.94; p < 0.0001) when compared to RCSEng guidelines. In particular, there was significant improvement in the documentation of assistants involved in the procedure (58% vs 98%; p < 0.0001), estimated blood loss (2% vs 63%; p < 0.0001) and specific mention whether the operation was emergency or elective (20% vs 86%; p < 0.0001). Conclusions Implementation of the new proforma showed significant improvement in operation note documentation when compared to the RCSEng standard. Therefore, this study emphasises the need for surgeons to familiarise themselves with the current guidelines and highlights the importance of tailoring local operation note proformas to match this national standard closely.

Aim Accurate and comprehensive operation notes are crucial for patient safety, quality assurance and medico-legal purposes. Inguinal hernia repair is one of the most common surgical procedures. Thus, operative documentation should be precise and standardised. The GROIN project aims to improve the quality of inguinal hernia operation notes using an evidence-based proforma and an operation note composition software. Methods We retrospectively reviewed operation notes of inguinal hernia repair performed at our institution between August and November 2022. Operation notes were assessed against the Royal College of Surgeons’ Good Surgical Practice standard, consisting of 18 items. Results The operation notes from 89 cases were reviewed. High-scoring items included: operation name (100%), operative findings (99%), surgeon's name (99%), closure technique (98%), operation date (90%) and signature (90%). Postoperative instructions were sufficiently detailed in 79% of cases. Regarding mesh placement, 63% of notes described mesh size and type, whereas 30% documented only the mesh type. The lowest-scoring items were: venous thromboembolism prophylaxis (31%), designation as elective or emergency (22%), operative diagnosis (6%), and estimated blood loss (2%). Conclusions We identified several areas for improvement in inguinal hernia operation notes based on our results. The next step of the GROIN project is to standardise operation note creation by implementing an evidence-based template, which will be delivered through a novel operation note composition software. This will allow accurate record-keeping and efficient operative data extraction analysis. Efforts to standardise operative notes and enhance their quality on a national and international level are imperative for patient safety.

Aims Accurate and comprehensive operation notes are crucial for patient safety, quality assurance and medico-legal purposes. Inguinal hernia repair is one of the most common surgical procedures. Thus, operative documentation should be precise and standardised. The GROIN project aims to improve the quality of inguinal hernia operation notes using evidence-based proformas and an operation note composition software. Method We retrospectively reviewed operation notes of inguinal hernia repair performed at our institution between August and November 2022. Operation notes were assessed against the Royal College of Surgeons' Good Surgical Practice standard, consisting of 18 items. Results The operation notes from 89 cases were reviewed. High-scoring items included: operation name (100%), operative findings (99%), surgeon's name (99%), closure technique (98%), operation date (90%) and signature (90%). Postoperative instructions were sufficiently detailed in 79% of cases. Regarding mesh placement, 63% of notes described mesh size and type, whereas 30% documented only the mesh type. The lowest-scoring items were: venous thromboembolism prophylaxis (31%), designation as elective or emergency (22%), operative diagnosis (6%), and estimated blood loss (2%). Conclusions We identified several areas for improvement in inguinal hernia operation notes based on our results. The next step of the GROIN project is to standardise operation note creation by implementing an evidence-based template, which will be delivered through a novel operation note composition software. This will allow accurate record-keeping and efficient operative data extraction analysis. Efforts to standardise operative notes and enhance their quality on a national and international level are imperative for patient safety.

Aim To assess adherence to the RCS Good Surgical Practice (2025) standards in HPB operative note documentation and additionally evaluate documentation of intraoperative adjuncts—Pringle’s manoeuvre, ICG fluorescence, intraoperative ultrasound (IOUS), and frozen section—in liver procedures. Method A prospective audit of 75 HPB operations was conducted. Operative notes were reviewed for compliance with RCS 2025 documentation standards, including key parameters such as incision, findings, complications, closure, estimated blood loss (EBL), prophylaxis, and postoperative instructions. Intraoperative adjunct documentation was analysed for liver procedures specifically. Results High adherence was observed for core parameters including incision (93%), findings (100%), closure (100%), postoperative instructions (100%), and surgeon signature (100%). Lower compliance was noted in the documentation of EBL (20%), specimen details (71%), and extra procedures (13%). Among 9 laparoscopic liver resections, ICG usage was documented in 2 cases (22%). Pringle’s manoeuvre was recorded in all applicable liver resections. IOUS and frozen section documentation were present in 25% and 30% of relevant cases, respectively. Conclusions This preliminary audit demonstrates strong compliance with core RCS documentation standards in HPB surgery. However, documentation of intraoperative adjuncts in liver procedures remains inconsistent. Planned interventions include implementing a standardised electronic operative note template, delivering educational sessions, and placing visual reminders in theatres. A second-cycle audit will be conducted in August, with loop closure planned by September.

Introduction Operation notes are critically important documents which serve as record for significant events in the lives of patients. They serve multiple functions, but chiefly to help guide peri-operative management. Surgeons must keep records that are accurate, thorough, and readable. This is fundamental part of the GMC’s Good Medical Practice as well as the Royal College of Surgeons of England Good Surgical Practice guidelines which lays out 18 various parameters for what should be included in an operation note. Aim This retrospective audit aimed to evaluate the compliance of neurosurgical operation notes with the Royal College of Surgeons guidelines, identifying areas for improvement. Method All neurosurgical procedures between October 1 and October 31, 2023, at a Major Trauma Centre in the West Midlands were retrospectively audited. Two independent reviewers used a standardized proforma in Microsoft Excel for data extraction, comparing compliance. Results 91 operation records were examined and found high compliance (100%) in key fields: date, surgeon's name, assistant's name, operative procedure, operative diagnosis, and signature. Negligible compliance was found in identification of prosthesis (0%), estimated blood loss (1%), extra procedures (1%), elective/emergency classification (1%), time (4%), and problems/complications (19.8%). Notably, detailed post-op instructions were lacking in over 1 in 3 operation notes, with 19.7% omitting DVT prophylaxis, and 20% neglecting clip/suture removal instructions. Conclusions While certain aspects showed exemplary compliance, critical deficiencies were identified, particularly in post-operative instructions. A template proforma for post op instructions is required in addition to more targeted guidelines for operation notes within neurosurgery.

IntroductionOperation notes are important documents for ensuring patient safety, effective communication between clinicians, and for medicolegal purposes. It is essential that they are clear and accurate. We audited the quality of our operation notes against the Royal College of Surgeons (RCS) of England's Good Surgical Practice Guidelines.MethodsThis was a prospective audit of 99 orthopedic trauma operation notes. In the first cycle, we audited 58 operation notes for orthopedic trauma surgical procedures. We audited 17 parameters per note. We presented our findings, implemented changes including the use of a typed operation note template, and performed a re-audit using 41 operation notes.ResultsOur documentation for 3/17 parameters was up to standard in both cycles. Post-intervention, there was an improvement in documentation for 12/17 of the parameters with marked improvements in indication for surgery (45% vs 75%), tourniquet time (20% vs 45%), antibiotic prophylaxis (71% vs 89%), closure technique (62% vs 86%) and detailed postoperative instruction (40% vs 92%). Other parameters, particularly estimated blood loss (7% vs 8%) remained unchanged. In the second cycle, we noted that 25% of the typed notes had 100% compliance with the standards, whereas no handwritten note achieved this. However, there was no statistically significant difference in the mean number of correctly documented parameters between the typed and handwritten notes (p < 0.05).ConclusionThe use of operation note templates (preferably typed) can improve appropriate documentation in orthopedic trauma operation notes. These templates should be made easily accessible to all surgeons. We will recommend orthopedic trauma units to apply similar non-rigid templates that can be tailored to suit different categories of trauma surgery.

Background Operation notes capture the key findings and details of a surgical procedure and are critical to its safety. The Royal College of Sur­geons of England has set an internationally accepted standard for elements of quality operation notes, but no prior research has considered the conformity of Ethiopian teaching hospitals with these standards. Methods A cross-sectional sample was collected at 2 Addis Ababa University teaching hospitals: Menelik II Hospital (MIIH) and Tikur Anbessa Specialized Hospital (TASH). Guided by the 2014 best practice guidelines released by the Royal College of Surgeons of England (RCSE), we retrospectively analysed the data of patients who underwent surgery between 1 August and 31 October 2017. Results All notes (n=348) were handwritten. At both hospitals, operative findings, anaesthesia details, patient position, and incision type were documented &gt;90% of the time. Residents wrote 98% of the notes at MIIH and 91% of the notes at TASH. Surgeons and as­sistants were identified in &gt;96% of the notes from MIIH and TASH, while anaesthesia team members were identified in 88.5% and 5.7% of the notes from MIIH and TASH, respectively. Gauze and instrument counts were documented in 81.2% and 69.5%, and clo­sure technique was described in 71.8% and 52.3% of the notes from MIIH and TASH, respectively. The operation note templates at both hospitals did not include fields for effective antibiotic prophylaxis, deep vein thrombosis prophylaxis, or estimated blood loss. Conclusions Operation notes in the studied hospitals were both incomplete and below the standards described by the RCSE guidelines, with specific concerns being insufficient documentation of technique and support staff, and missing documentation of antibiotic prophylaxis and blood loss. We recommend that Addis Ababa University implements a new operation note format incorporating RCSE requirements, increase the level of supervision provided by senior surgeons for notetaking, and improve surgical documen­tation training in the residency curriculum.

In the UK, doctors are instructed to keep accurate and clear medical records. This helps to ensure patient safety and is a professional expectation from the General Medical Council (GMC). However, operation note documentation is often reported to be sub-optimal despite general guidelines from the Royal College of Surgeons of England (RCSeng) existing. These guidelines have sub-domains, e.g. estimated blood loss, which can inform the understanding of an intra-operative complication to help guide post-operative management. We conducted a closed loop audit of operative notes against these guidelines to ascertain if neurosurgeons in our department thought them applicable to neurosurgical practice. The first cycle was conducted retrospectively and the second cycle prospectively each conducted over a four-week period. In between each cycle the results were presented to the department: firstly, as an oral presentation and secondly as posters displayed in relevant clinical areas. Furthermore, the knowledge of operative note guidelines and their perceived importance by registrars were ascertained through a questionnaire. This highlighted that RCSeng sub-domains missing from operation notes scored lowest in terms of importance, and one sub-domain that remained recorded less frequently in both cycles was estimated blood loss. This reflects closed loop audits in general, plastic and orthopaedic surgery. Clearly, a generic guideline cannot be completely applicable to neurosurgical practice. This then begs the question if such a guideline is useful at all. Or should guidelines be specialty specific, as is the case in orthopaedic surgery, to improve compliance to a guideline more reflective of neurosurgical practice.

Aims Accurate and comprehensive operation notes are essential for patient care, quality assurance and medico-legal purposes. Laparoscopic cholecystectomy is a common procedure where the quality of operative documentation can impact future patient care. The LaCON project aims to evaluate and improve the quality of LC operation notes with a view to implementing a novel software for standardised operation note creation. Method We retrospectively reviewed operation notes of LCs performed at our institution between August and November 2022. Electronic notes were assessed against the Royal College of Surgeons' Good Surgical Practice standard, consisting of 18 items. Results We assessed a total of 80 operation notes. There was 100% compliance in surgeon's name, operation name, incision, port placement, and closure technique. High-scoring items included indication (98%), operative findings (98%), operation date (91%) and assistant's name (90%). Among the lowest-scoring items were detailed postoperative instructions (46%), designation as elective or emergency (38%), intraoperative complications-problems (36%), additional procedures performed (23%), operative diagnosis (16%) and estimated blood loss (8%). Conclusions We identified several areas for improvement in LC operation notes. The next step of the LaCON project is to standardise operation notes by implementing an evidence-based standardised proforma for LC. This will be accessible through an online app that integrates with our hospital's electronic record system. It will also allow the extraction of operative data for research and audit purposes. This integrated online system has the potential for wider distribution across other procedures, specialities and centres to ensure high standards of safety and care and enhance collaborative multi-centre research.

Postoperative Antibiotics Correlate with Worse Outcomes after Appendectomy for Nonperforated Appendicitis

Introduction Constructing an accurate and comprehensive operation note is an important process in a patients’ journey as it should provide sufficient information to allow continuity of care by other healthcare professionals. We performed an audit of operation notes in colorectal surgery to assess whether they meet the standards as described by the Royal College of Surgeons. Method Retrospective data was collected over a period of 10 months to include all major elective colorectal operations. Operation notes were scrutinised for all 17 relevant data points as described in Good Surgical Practice. The electronic patient system at our trust populates the operation note with date/time, surgeons and anaesthetist. Results There were a total of 232 major colorectal procedures performed between May 2020 and March 2021. 12 data points were adhered to 100%. Estimated blood loss was only documented in 18.1% (n=42) of operation notes. Pre-operative DVT prophylaxis was documented in 6% (n=14) of operation notes. Details of tissue removed were not documented in 3% (n=7) of operation notes. Antibiotic prophylaxis was not documented in 1.7% (n=4). Theatre anaesthetist was not documented in 1.3% (n=3) of operation notes. Conclusions Operation notes in electively colorectal surgery are not meeting the standard as set out in Good Surgical Practice. There is a potential for change by adding drop down sections on the electronic operation note to ensure all operation notes meet the standards and are uniform. These changes will be trialled and the data re-audited in the near future.

Context Operative notes should be documented “ clearly, accurately and legibly ” – as endorsed by the GMC’s Good Medical Practice. The RCS Eng. Guidelines (2014) advocate contemporaneous, complete surgical records. This audit identified significant shortcomings in operative documentation amongst paediatric general surgical cases in a tertiary care centre. Data collection was performed by two FY1s and a Surgical Registrar. Problem Surgical operation notes necessitate accurate documentation from both a medico-legal and professional perspective; whilst comprehensive records facilitate post-operative patient management. However; in practice they are frequently sub-standard, thus raising concerns towards patient safety. Current operative note templates within our unit fail to comply with relevant guidelines. Assessment of problem and analysis of its causes We identified poorly-documented details within general surgical operation notes using a data collection tool incorporating pertinent, recently-published guidance. Areas for improvement included: patient’s weight, type of procedure performed (i.e. emergency vs. elective), whether surgery was with or without complication, and antibiotic prophylaxis. Results attained were compared against data from previous audits of a similar nature (carried out in 2010 and 2011 respectively). Intervention Our proposed intervention involves promoting typed documentation of operative notes, whilst advocating their transition from paper text to an electronic format. We plan to achieve this through usage of a unique, pre-existing computerised system developed by a consultant within the department, which additionally populates our current Trakcare system upon document creation. We hope to educate the entire general surgical team in its practice. Furthermore, we will introduce informative posters highlighting the RCS Eng. guidelines and reiterating imperative operative details within the main theatres and day surgery unit. Letters detailing the audit’s key findings and our intended strategy for change were sent to all consultants and surgical trainees. Study design Prospective analysis of 138 general surgical operative notes identified over a 2-week period. We created a 26-point core checklist incorporating both RCS (Eng.) 2014 and GMC “ Good Medical Practice ” 2013 guidance. We then audited elective and emergency operative documentation against this standardised proforma. Data collected was subsequently evaluated once compiled onto a computerised spreadsheet (Table 1). Strategy for change Our findings were presented at the weekly departmental meeting, where we emphasised the need for operative note improvement. Proposed interventions were then implemented at the earliest opportunity. In particular, details not previously recorded, yet strongly advocated, by the RCS Eng. were promoted (e.g. anticipated blood loss, DVT prophylaxis etc.). Measurement of improvement We intend to re-audit operation notes in 2–3 months’ time, using an identical proforma to record data, once the proposed interventions have been implemented. We will determine whether results attained are statistically significant by calculating p-values and using simple statistical data analysis. Effects of changes We anticipate enhanced operative note standards as a result of introducing the proposed interventions. Our aspiration is to generate discussion in computerised documentation of surgeries and inspire greater numbers of surgeons to make use of electronic systems to ensure operative notes are both standardised and increasingly legible. Lessons learnt Surgeons were receptive to this study’s findings and were genuinely keen to improve upon their own operative documentation. Concerns were raised as to whether certain areas of documentation advised by the RCS Eng. are applicable to the paediatric populace e.g. DVT prophylaxis. This highlighted the importance of considering your patient cohort when formulating an operative note template. Message for others We envisage the future of operative notes to be an electronic format. However, until this is achieved we recognise that the majority of surgeons will continue to use our current paper-based arrangement. Thus, we believe that typed operative documentation (using the methods described above) is an acceptable platform towards ameliorating the existing Trakcare system.