Handwritten Operative Note Compliance in Plastic Surgery.
Published Date: 30th August 2023
Publication Authors: Harper-Machin A
Abstract
Accurate and comprehensive documentation of operations is crucial to optimise patient care. Omissions may cause compromised management, or medicolegal issues. A closed-loop audit was completed at a plastic surgery centre to identify whether Royal College of Surgeons (RCS) standards were met. It aimed to identify and address limitations of hand-written notes, which were completed free-hand or on departmental proformas (burns, bite, Mohs, skin and hand).
Method
Mandatory operative note domains were taken from the RCS guidance within Good Surgical Practice (2013). Acceptable compliance in domains was agreed at 90%. Cycle-one included all operations performed by the department over three days in November 2021. In cycle-two, a twenty-operation sample was taken across one week in May 2022.
Result
Compliance was met in the domains of date (100%), surgeon (100%), procedure (92.7%), diagnosis (95.1%), findings (95.1%), closure (93.9%), antibiotics (100%) and post-operative instructions (100%). Domains below standard included: time (32.9%), anaesthetist (60.9%), incision (78.0%) and blood-loss (2.4%). As a result, proformas were modified to include domains below standard (if not already included). On re-audit, no new domain achieved agreed standard.
Conclusion
Whilst most domains met agreed standards, a lack of improvement on re-auditing demonstrates challenges in paper documentation. Paper-noting for some may be more time consuming and susceptible to omission of required information. Whilst not feasible in this instance, transitioning to e-noting may improve compliance, due to automations and the ability to mandate certain fields. In the interim, a generic paper template may be advantageous for operations not covered by proformas.
Ridgley, J; Harper Machin, A; et al. (2023). Handwritten Operative Note Compliance in Plastic Surgery. British Journal of Surgery. 110(Suppl 7). [Online]. Available at: https://dx.doi.org/10.1093/bjs/znad258.165 [Accessed 5 January 2024].
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