Audit of Operation Notes in Plastic and Reconstructive Surgery Unit, All Africa Leprosy Tuberculosis and Rehabilitation Training Center (ALERT) Hospital
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Date
2021-12
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Addis Ababa University
Abstract
Introduction: High quality operation notes are one of the most crucial parts of patient care as it
is a means of communication among professionals, source of data for audits and researches, and a source of information in court. The Royal College of Surgeons of England has produced a
guideline in 2014 that outlines the minimum standards that need to be documented on operation
notes. This study aims to assess the adherence of ALERT hospital plastic and reconstructive unit
to these guidelines.
Objectives: To evaluate operation notes in the plastic and reconstructive unit of ALERT hospital
against RCSEng GSP 2014 standards, identify causes of incompleteness and suggest possible
ways of improvement in the quality of operation notes.
Methods: The study is conducted, plastic and reconstructive unit of ALERT hospital. It is a
cross sectional retrospective study conducted using stratified random sampling of 341operation
notes written since April 1, 2020, supplemented by survey questionnaire administered to 22
doctors (consultants, fellows and residents) to assess their experience and opinion regarding
operation note standards.
Results: None of the RCSEng GSP 2014 standards were consistently documented. Only 3
standards were documented in more than 90% of operation notes. Most operation notes were
written by residents. Survey questionnaire administered results showed the participants believe
that lack of quality of operation notes affects follow up and future interventions for patients.
More than 95% of the respondents reported that they do not write all the standards consistently
and most commonly attributed reasons are absence of formal education on the subject and
operation note proforma incompleteness according to the standard. Among the measures
suggested by the survey participants to improve the quality of operation note include
introduction of formal teaching about operation note writing, updating the existing operation
note proforma to include the RCSEng GSP 2014 standards and educating the staff about the
standards.
Conclusion: Operation notes in plastic and reconstructive surgery unit of ALERT hospital are
not up to standard per RCSEng GSP 2014 guideline. Formal education, update of existing
operation note proforma, posting aide memoires in the operation theatres and clinical education
of the staff about the standards are some of the proposed solutions to improve the quality of the
operation notes.
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Keywords
Audit ,Operation,Plastic , Reconstructive Surgery