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Abstract Introduction Operation notes are an important component of a patient’s medical record. Accurate documentation of surgical procedures is essential to understand the details of the operation and the post-operative management plan. The aim of this audit was to assess the current practices of documentation of operation notes, identify shortcomings, and compare the outcomes after introduction of recommendations made by the Royal College of Surgeons (RCS) of England in 2014. Methods This retrospective and prospective closed-loop audit was conducted in August-September 2021 at Basharat Hospital, Rawalpindi, Pakistan. 125 operation notes were evaluated to analyze the current documentation practices. The findings of the initial audit were compared with the Royal College of Surgeons (RCS) guidelines of Operation notes documentation. A re-audit was carried out after implementation of the improved version of operation notes. A panel reviewed 125 operation notes for adherence to international guidelines. Results The documentation rate was increased from 37.5% to 83.3% after the completion of this closed loop audit. Documentation of timing of surgery, operative findings, complications, additional procedure performed, anticipated blood loss, closure technique and deep vein thrombosis (DVT) prophylaxis were noted to be lacking in the initial audit. Implementation of the RCS guidelines revealed an improvement in the documentation of all parameters, with documentation rates exceeding 83% and an overall improvement of 45.8%. Conclusion This audit signifies the positive impact of RCS guidelines on the quality of operation notes documentation. Such audits should be regularly conducted for refined documentation practices, and enhanced patient care and safety.
Shafique et al. (Sun,) studied this question.