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June 13, 2026Frontiers in SurgeryOpen Access

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

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Authors

AKAjay KamatAPAshvath Arumugam PillaiUAUpasna Ajmani

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Overview

Randomized trial evaluated orthopedic note quality in a tertiary care hospital, indicating significant improvement post-intervention.

Key Points

  • The audit aimed to assess orthopedic operative note quality against established RCSE and BOA standards.
  • Single-cycle audit of 100 randomly selected orthopedic operative notes from January–June 2023.
  • Implementation of a standardized documentation template and staff training between July–October 2023.
  • Re-audit of 100 notes from October 2023–March 2024 to evaluate the impact of interventions.
  • Baseline compliance rates were low: patient identification (72%), intraoperative findings (65%), postoperative plan (58%), surgeon details (70%).
  • Post-intervention re-audit showed compliance improved significantly: patient identification (95%, p < 0.001), intraoperative findings (95%, p < 0.001), postoperative plan (90%, p < 0.001), surgeon details (97%, p < 0.001).
  • Overall protocol adherence improved from 68% to 95% (p < 0.001) with persistent non-compliance in postoperative plan documentation (10%).

Cite This Study

Kamat et al. (2026) studied this question.

synapsesocial.com/papers/6a2cf2a9faef96ed7f05561fhttps://doi.org/10.3389/fsurg.2026.1704348
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