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Improving the quality of orthopaedic elective and trauma operative notes: A completed audit loop study

Shah, PA; Badiani, R; Davis, BM; Kalairajah, Y; (2016) Improving the quality of orthopaedic elective and trauma operative notes: A completed audit loop study. International Journal of Surgery Open , 3 (C) pp. 14-17. 10.1016/j.ijso.2016.04.005. Green open access

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Abstract

Introduction: Good medical practice dictates that comprehensive documentation of all surgical procedures is paramount in maintaining a high standard of patient care. This study audited the quality of operative note keeping for elective and trauma procedures against the standards set by the British Orthopaedic Association (BOA) and The Royal College of Surgeons of England (RCSE) guidelines. Patients and methods: A retrospective assessment of the operative notes of every patient undergoing a total knee and hip replacement (elective cases) was carried out over a period of 2 months. Data recorded were compared against BOA guidelines. Within this time a randomised selection of trauma operative notes were also assessed, and the recorded data were compared against RCSE guidelines. Change in practice was implemented and the audit cycle completed. A total of 173 operative notes were evaluated. Results: There was a significant improvement (p-value < 0.05) in the quality of total knee replacement notes, with an increase in the percentage of data points from 68.6% to 93%. Similarly the quality of total hip replacement notes showed significant improvement (p-value < 0.01) with an increase in the percentage of data points from 67.5% to 86%. However trauma operative notes showed minimal improvement. Discussion: This study showed that the quality of elective operative notes was improved through surgeon education and the circulation of a guideline based electronic operative note. We have further plans to implement procedure specific notes for the most common types of trauma cases to help improve the quality of trauma operative notes.

Type: Article
Title: Improving the quality of orthopaedic elective and trauma operative notes: A completed audit loop study
Open access status: An open access version is available from UCL Discovery
DOI: 10.1016/j.ijso.2016.04.005
Publisher version: http://dx.doi.org/10.1016/j.ijso.2016.04.005
Language: English
Additional information: © 2016 The Authors. Published by Elsevier Ltd on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
UCL classification: UCL
UCL > Provost and Vice Provost Offices
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Brain Sciences
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Brain Sciences > Institute of Ophthalmology
URI: https://discovery.ucl.ac.uk/id/eprint/1514924
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