A Chink in the Armour? — “Good Surgical Practice” Audit of Operative Notes

A thorough and accurate operative note is an essential part of a good surgeon’s armamentarium. It serves as a crucial guide for postoperative patient care and has medico-legal ramifications. To assess the quality and completeness of operative notes in comparison with Royal College of England (RCSEng) guidelines, we, in a tertiary care hospital, conducted a closed-loop audit analysis of 100 random operative notes, for completeness and accuracy. The major deficiencies were details of operative findings, estimated blood loss, identification of prosthesis, and mention of venous thromboembolism prophylaxis. After highlighting these lacunae, we educated surgeons and surgical trainees on the “Good Surgical Practice” recommendations by RCSEng. After the implementation of a new proforma for operative notes, a reaudit was done of 100 random operative notes after 3 months, to check for compliance. The overall quality of operative notes improved particularly with respect to date and time of surgery, operative findings, estimated blood loss, identification of prosthesis, and mention of thromboembolism prophylaxis.