Improving the quality of orthopaedic elective and trauma operative notes: A completed audit loop study

• An audit of the quality of operative notes for elective and trauma procedures.
• 173 notes audited against guidelines set by the RCSE and BOA.
• Intervention was the circulation of a guideline based electronic operative note.
• After re-audit, improvement seen in the quality of elective but not trauma notes.
• Further work to implement procedure specific notes for the most common trauma cases.

IntroductionGood medical practice dictates that comprehensive documentation of all surgical procedures is paramount in maintaining a high standard of patient care. This study audited the quality of operative note keeping for elective and trauma procedures against the standards set by the British Orthopaedic Association (BOA) and The Royal College of Surgeons of England (RCSE) guidelines.Patients and methodsA retrospective assessment of the operative notes of every patient undergoing a total knee and hip replacement (elective cases) was carried out over a period of 2 months. Data recorded were compared against BOA guidelines. Within this time a randomised selection of trauma operative notes were also assessed, and the recorded data were compared against RCSE guidelines. Change in practice was implemented and the audit cycle completed. A total of 173 operative notes were evaluated.ResultsThere was a significant improvement (p-value < 0.05) in the quality of total knee replacement notes, with an increase in the percentage of data points from 68.6% to 93%. Similarly the quality of total hip replacement notes showed significant improvement (p-value < 0.01) with an increase in the percentage of data points from 67.5% to 86%. However trauma operative notes showed minimal improvement.DiscussionThis study showed that the quality of elective operative notes was improved through surgeon education and the circulation of a guideline based electronic operative note. We have further plans to implement procedure specific notes for the most common types of trauma cases to help improve the quality of trauma operative notes.