Facts about compliance of surgeons “An audit study of the quality of operation notes in the department of general surgery, King Faisal Hospital, Makkah, Saudi Arabia
Abstract
Background: An accurate, complete, legible medical record implies accurate, complete organized assessment and management of the patient. Operation notes as one of the important patient’s
medical records are often produced as evidence in medico-legal cases. In a court of law, that which is not written down may be perceived as never having occurred. Poorly written and illegible notes, along with the use of confusing abbreviations, are a common source of weakness in a surgeon's
defense.
Objectives: This audit was carried out mainly to assess and review the compliance and adhere of surgeon to existing operation guidelines sheet of ministry of health (form 15), and to enhance professionalism.
Methodology: In this retrospective audit, 266 operation notes were reviewed in general surgical department of King Faisal Hospital, Makkah, Kingdom of Saudi Arabia, during a period of six months (January - June 2007). Because we have no standing ethical committee in our hospital the
approval and permission were given by the administration for this study. Notes were scrutinized and reviewed for the quality, accuracy of patient’s personal data, details of operation and name of surgeon, operating team, details of operation, swabs, instruments counts, as well as for the inclusion
of unacceptable abbreviations. The standard operation sheet (form 15) guideline of Ministry of Health, Kingdom of Saudi Arabia, attached to the patient’s file was used as a reference.
Results: None of the notes were completely filled in this audit, some of important vital data of patients e.g. identification data were missed in (122 patients 45.9 %), and usage of non standardized abbreviations was found in 118 (44.4%). The types of the operation (emergency/elective) was
recorded in 179 (67.3%) of all the operative notes. The time of the operation was recorded in 129 (48.5%) of the operative notes. Wound closure details were recorded in 153 (57.5%) of the notes and many other data like name of surgeon, anesthesiologists, type of anesthesia were variably missed.
Conclusion: We conclude that a simple compliance to the attached operation note sheets can significantly improve the quality of the notes, continuity of care and potentially avoid medico-legal problems. There is an urgent need for revision and modification of form No: 15 operation sheet of Ministry of Health as well as introduction of computer database in operation notes. This should be an issue for the Faculty of Medicine, making the training of future surgeons more effective
References
Reed MW, Phillips WS. Operating theatre lists -accidents waiting to happen? Ann R Coll Surg Eng 1994; 76:279-280
Guidelines.(2002) Good surgical practice, Royal College of Surgeons. 14-15
Moore RA. The dictated operative note: important but is it being taught? J Am Coll Surg 2000; 190(5):639-640.
Eichholz AC, Van Voorhis BJ, Sorosky JI etal. Operative note dictation: should it be taught routinely in residency programs? J Obstet Gynecol 2004; 103(2):342-346.
Flynn MB, Allen DA. The operative note as billing documentation: a preliminary report. Am Surg 2004; 70(7):570-574.
Edhemovic I, Temple WJ, de Gara CJ et al. The computer synoptic operative report--a leap forward in the science of surgery. Ann Surg Oncol 2004; 11(10):941-947.
Nicopoullos JD, Karrar S, Gour A et al. Significant improvement in quality of caesarean section documentation with dedicated operative proforma--completion of the audit cycle. J Obstet Gynaecol 2003; 23(4):381-386.
The Royal College of Surgeons of England. Guidelines for Clinicians on Medical Records and Notes, London: The Royal College of Surgeons of England, 1994. 9. Rodger J. Medical and Dental Defence Union of Scotland. Personal Communication.
Dale RF, Midwinter MJ. Use of database management system by surgeons to produce operation notes. Ann R Coll Surg Engl 1996; 78(6 Suppl):272-275.
Cohen MM, Ammon AA. A solution to the problem of undictated operative reports by residents. Am J Surg 1998; 176:475–80
