Improving Operative Note Quality Through Standardized Documentation A Closed-loop Audit In The Plastic Surgery Unit (Atbara-Sudan)

Improving Operative Note Quality Through Standardized Documentation A Closed-loop Audit In The Plastic Surgery Unit (Atbara-Sudan)

Nagla Mustafa Ibnouf Mohamed , Momen Mohamed, Ahmed Abbas Ahmed Saeed, Sara Amin, Zahraa Khider, Aya Yousif, Omsalma Hussein
Sudan Medical Specialization Board, Khartoum, Sudan; Omdurman Teaching Hospital, Khartoum, Sudan; Police Hospital Atbara, Atbara, Sudan

Introduction: The documentation of medical records is a fundamental form of communication that enables the sharing of information and supports the continuity of care within the medical team. Operative notes, a key component of medical records, are particularly critical in surgical settings. . This study aimed to assess the quality of notes in our unit.

Methodology: A closed loop audit in a plastic surgery unit where in the first cycle we did retrospective assessment of 30 operative notes against the published standards of the Royal College of surgeons of England using a checklist. Following data analysis, an intervention has been made in the form of doctor education and an introduction of a standardized template form. A further prospective 30 operative notes were collected following the intervention, and rates of compliance were compared before and after. The data was analysed using the SPSS (26) with P < 0.05 considered to be statistically significant.

Results: The initial audit revealed missing data on the type of surgery, extra procedures done, estimated blood loss, intraoperative complications and deep vein thrombosis prophylaxis. Following our intervention a significant improvement was detected in all parameters after re audit. Overall documentation completeness has increased, results of the paired-sample t-test indicated that there is a significant large difference in documentation quality of operative notes before and after the introduction of the new proforma

Conclusions: It highlighted the importance of using standardization in documentation to improve the quality of medical care delivery, leading to increase patient safety and reduce litigations.

Keywords: Medical Record, Operative Notes