Elevating orthopedic documentation: a clinical audit of orthopaedic operative note quality against RCSE and BOA standards

Background The main aim of this audit was to measure the performance of the orthopedic Operating Theatre (OT) notes as compared to the standards laid down by the Royal College of Surgeons of England (RCSE), British Orthopedic Association (BOA) and their collaborators. Methods This single-cycle audit was conducted in the Department of Orthopaedics of a tertiary care hospital. One hundred randomly selected orthopaedic operative theatre notes from January–June 2023 were assessed against RCSE and BOA documentation standards. Following identification of deficiencies, targeted interventions were implemented between July–October 2023, comprising a standardised documentation template and a staff training programme. A re-audit of 100 notes was subsequently performed from October 2023–March 2024 to evaluate the impact of these interventions. Domain-specific compliance rates were compared between cycles using the chi-square test. Results Baseline audit identified deficiencies across four documentation domains: patient identification (72%), intraoperative findings (65%), postoperative plan (58%), and surgeon details (70%). Following the intervention programme, re-audit demonstrated significant improvements in all domains: patient identification (95%, p < 0.001), intraoperative findings (95%, p < 0.001), postoperative plan (90%, p < 0.001), and surgeon details (97%, p < 0.001). Overall protocol adherence improved from 68% to 95% ( p < 0.001). Persistent deficiency was noted in completeness of postoperative plan documentation (10% non-compliance at re-audit). Conclusion A single audit cycle with targeted training and a standardised template produced statistically significant improvements across all RCSE/BOA documentation domains. Incorporating operative note training into routine induction programmes for rotating staff is recommended to sustain these gains.