Surgical Operative Notes Compliance with the Standard Guidelines of the Royal College of Surgeons: A Retrospective Clinical Audit at a Tertiary Hospital in Bangalore, India

Abstract

Introduction: Operative notes are essential documents that record the operative findings and procedures performed during surgeries. Therefore, it is crucial to document them with clarity and objectivity. They serve various purposes, including auditing, teaching, research, and providing valuable information in medicolegal cases. Aim: To assess the accuracy of operative note-keeping in accordance with the guidelines set by the Royal College of Surgeons (RCS) of England. Materials and Methods: A retrospective clinical audit was conducted to evaluate the quality of operative notes in the Department of General Surgery at St. John’s Medical College and Hospital in Bengaluru, Karnataka, India, from June 2022 to October 2022. A total of 75 surgical notes were analysed, including cases of both elective and emergency surgeries. The audit assessed all 19 parameters mentioned by the RCS. A master sheet was created to record the analysed variables, and each variable was categorised as present, absent, or not applicable. Statistical analysis was performed using the Statistical Package for Social Sciences (SPSS), version 21.0, and the results were expressed as percentages. Results: The documentation of the surgeon’s name, diagnosis, intraoperative findings, and procedure performed was accurate in both groups, comprising 45 (100%) cases of elective surgeries and 30 (100%) cases of emergency surgeries. However, there was a lower compliance with Deep Venous Thrombosis (DVT) prophylaxis in both groups, with 10 (22%) cases in elective surgeries and 4 (13%) cases in emergency surgeries. Conclusion: Based on the findings of the present study, it is recommended to adhere more strictly to the guidelines provided by the RCS of England, particularly in emergency cases. Regular audits should be conducted to ensure quality management, enhance surgical training, and address medicolegal implications effectively.