Royal College of Surgeons Guideline Adherence on Improvement of Operative Notes: A Six-Month Closed Loop Audit

摘要

Introduction Every surgical procedure is followed by thorough and descriptive documentation. The Royal College of Surgeons (RCS) introduced official guidelines in 2014 on the proper documentation of operative notes. These guidelines are concise, targeted, and easy to adapt to any surgical specialty. Methods and results An audit was conducted from April to September 2019 at District Headquarter Hospital in Rawalpindi, Pakistan. We analyzed 215 operative notes of elective and emergency cases during the first three months (pre-implementation), and after comparing the notes against the RCS orthopedic notes guidelines, we developed a dedicated notes format for use in the second three months (post-implementation). A panel reviewed 235 notes postimplementation for legibility and compliance with the 2014 RCS guideline data. Operative diagnosis was written in 80% pre-implementation notes and 100% of post-implementation notes. Pre-implementation of RCS guidelines, 78% of operative notes included the names of the anesthetist and the operative staff, 88% included assistant names, and 90% included the name of the operating surgeon. Post-implementation, these numbers increased to 92%, 93%, and 99%, respectively. All domains of the guideline were filled, and data point inclusion statistically significantly improved (0.001 P 0.005) after the implementation of RCS guidelines. Conclusion Following the RCS guidelines resulted in a significant improvement in all deficient fields in operative notes.