Structured Format, Training and Audit Improves the Quality of Operative Notes

Maintaining good medical records is an integral part of good medical practice. Operative notes are one such record. In our institute, there is no uniform format of operative notes. With this audit, we analyzed the deficiencies in the existing formats; made a new structured format based on the Royal College of Surgeons official guidelines and our department’s needs; and held training sessions to sensitize the trainees and faculty about the need, use, and method of better documentation. A prospective audit was conducted starting October 2020 to December 2020. A total of 97 notes were analyzed. In the first audit, 45 operative notes entered in October 2020 were scrutinized and reviewed for completeness. These were compared to 52 operative notes filled in December 2020 post-introduction of a new structured format and training. Results of both the audits were compared to assess the impact on documentation. There was an improvement in documentation in almost all deficient fields. Pre-implementation < 50% of notes included important demographic data; post-implementation, it improved to > 75%. Diagnosis was mentioned in 51% of notes earlier which increased to 84% post-implementation. Operative findings were written in 57.6% of the notes pre-implementation; it increased to 94.2% post-implementation. Only 8.9% of the notes mentioned the name of the doctor compiling the notes earlier, whereas post-introduction of new structured format name was mentioned in 67.3% of notes. Introduction of a new structured format, sensitization and training sessions led to an improvement in documentation in all the fields of operative notes.