quality of operation notes audit presentation
TRANSCRIPT
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Audit on the Quality of
Operation Notes
Dr P. Sandhu
Dr P. Lakhtaria
Mrs A. CarmichaelMrs S. Fitter
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Aims & Objectives of the Audit:
To assess the quality of operating notes in
accordance with the guidelines from the
Royal College of Surgeons of England.
To assess if continuity of care can be
established.
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About the Audit:
Type:
A prospective, multi-professional audit to look atthe quality of operation notes within the Trust.
Source:
100 sets of notes were assessed against nationalguidelines from the Royal College of Surgeons of
England and other parameters set locally.
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Analysis:
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Type of Procedure:
88%
12%
Elective Emergency
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Grade of Surgeon:
40%
56%
4%
Cons SPR SHO
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Variables assessed according to
guidelines of the Royal College of
Surgeons of England
(from- Guidelines (2002). Good Surgical Practice,
The Royal College of Surgeons, England, 14-15.)
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Date and Time.
Elective/ Emergency procedure.
Name of operating surgeon and the assistant.
The operative procedure carried out.
The incision.
The operative diagnosis.
The operative findings.
Any problems/ complications.
Any extra procedure performed & reason why it wasperformed
Details of tissue removed, added or altered.
Identification of any prosthesis used, including serial no ofprostheses & other implanted materials.
Details of closure technique.
Post operative care instructions.
Signature.
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Was the Date and Time recorded?
9%
91%
Both Just Date
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Was the Type of Procedure recorded?
100% did not record the type of procedure
(elective / emergency).
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Was the Name of the Operating Surgeon
and the Assistant recorded?
99%
1%
Yes No
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Was the Operative Procedure recorded?
98%
2%
Yes No
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Was the Incision recorded?
95%
5%
Yes No
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Was the Operative Diagnosis recorded?
66%
34%
Yes No
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Were the Operative Findings recorded?
94%
6%
Yes No
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Was there any record of Complications?
10%
90%
Yes No
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Was any extra Procedure performed (i)?
If Yes, was the reason why it was performed recorded (ii)?
9%
91%
Yes No
(i)
89%
11%
Yes No
(ii)
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Were the details of any tissue removed, added
or altered recorded?
79%
21%
Yes No
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Was the identification of any prosthesis used, inc. the serial
number of prostheses and any other implanted materials
recorded?
3%8%
89%
Yes No N/A
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Were the details of the closure technique
recorded?
98%
2%
Yes No
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Were any postoperative care instructions
recorded?
73%
27%
Yes No
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Was a signature recorded?
75%
25%
Yes No
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Other Variables assessed:
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Was a diagram drawn to show the findings?
15%
85%
Yes No
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Was the handwriting legible?
34%
21%
45%
Yes No typed
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Were abbreviations used (i)?
If Yes, were they clear or unclear (ii)?
18%
82%
Yes No
(i)
83%
17%
Clear Unclear
(ii)
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Does the quali ty of notes enable continuity of care?
Our main concern is whether the operation notes
would be able to stand up in a court of law.
The following points were considered whiledetermining if the notes enabled continuity of care.
Poor handwriting/legibility.
Incorrect / missing information, e.g. DOB.
Lack of diagrams
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Inadequate information- e.g.
Procedure explained as routine.
No description of the type of repair done for a hernia.
Two procedures done electively but notes for both
written together & mixed up. Postoperative orders given as discharge when safe.
Use of vague and incomprehensible abbreviations.
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Does the quali ty of operation notes enable
continuity of care?
77%
23%
Yes No
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Recommendations:
Regular revision of guidelines regarding medical
record keeping during weekly meetings.
Use of standard electronic form in the main theatre
(where most of the operation notes are typed).
Changes in the format of the operation note sheet
of the trust ??
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THANK YOU