What type of study is this?

This is a Clinical Audit study.

September 10, 2025Open Access

Assessing the Quality of Operative Notes in the Orthopedic Surgery Department at Gezira Traumatology Center, Sudan, in Accordance With the Royal College of Surgeons Guidelines

Key Points

Post-intervention, compliance improved for key documentation elements like anesthetist's name at 82.6%, but declines were noted in prosthesis documentation.
The audit analyzed 23 retrospective orthopedic operative notes against 14 Royal College of Surgeons parameters, showing initial high compliance in some areas.
Multi-faceted interventions included staff education and a standardized template to address identified deficiencies in documentation quality.
Although overall compliance improved, focus on specific details like prosthesis identification remains critical for sustaining high-quality surgical documentation.

Abstract

Background: High-quality operative notes are crucial for patient safety, continuity of care, and medico-legal protection. Despite established Royal College of Surgeons (RCS) guidelines, audits globally reveal persistent deficiencies in surgical documentation. This study assessed the quality of operative notes in the Orthopedic Surgery Department at Gezira Traumatology Center, Wad Madani Teaching Hospital, Sudan, and evaluated the impact of targeted interventions. Methods: A clinical audit was conducted in two cycles (in July 2023 and then three months post-intervention). In the first cycle, 23 randomly selected orthopedic operative notes were retrospectively audited against 14 RCS documentation parameters. Root cause analysis identified key deficiencies. A multi-faceted intervention was implemented, including staff education, a standardized RCS-aligned template, visual reminders, and a feedback mechanism. The second cycle re-audited 23 notes using the same criteria. Data were analyzed using descriptive statistics. Results: Pre-intervention, compliance was high for procedure (95.7%), diagnosis (95.7%), and signature (100%), but critically low for theatre anesthetist's name (4.3%), anticipated blood loss. (13%), and antibiotic prophylaxis (8.7%). Post-intervention, significant improvements were noted in documenting the anesthetist's name (82.6%), anticipated blood loss (82.6%), complications (91.3%), and antibiotic prophylaxis (69.6%). However, unexpected declines were observed in documenting prosthesis identification (from 87% to 26.1%) and tissue details (from 87% to 65.2%). High-compliance areas generally remained stable. Conclusion: Implementing a standardized operative note template based on RCS guidelines, combined with education and feedback, significantly improved the completeness of critical documentation elements in orthopedic operative notes. The decline in documenting prosthesis and tissue details highlights the need for focused reinforcement and ongoing monitoring to achieve consistent, comprehensive compliance. Standardized templates are highly effective tools for enhancing surgical documentation quality.

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Cite This Study

Alnour et al. (Wed,) studied this question.

synapsesocial.com/papers/68c1b81854b1d3bfb60ec41e https://doi.org/https://doi.org/10.7759/cureus.89492

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