Keywords
clinical audit - documentation quality - quality improvement - low- and middle-income
countries - surgical operative notes
Surgical operative notes are vital for patient treatment, serving as essential legal
records and key communication instruments for multidisciplinary medical teams. The
Royal College of Surgeons of England (RCSEng) highlights the necessity of accurate,
comprehensive, and timely recording of surgical interventions to maintain high standards
of patient care and provide medicolegal security.[1] These records offer a detailed account of the surgery, aid in postsurgery care,
and ensure seamless continuity of treatment across different health care professionals.
Furthermore, they are indispensable for clinical reviews, efforts to improve quality,
and for training purposes, thereby boosting patient safety and fostering professional
advancement.[2]
Deficiencies in the documentation of surgical operative notes can create substantial
legal and ethical problems. From a legal standpoint, insufficient records can lead
to disagreements regarding the quality of care administered, potentially making health
care providers vulnerable to accusations of malpractice. Ethically, incomplete notes
jeopardize patient safety and the continuity of care because vital details might be
absent, obstructing effective postsurgery management. Precise and detailed operative
notes are crucial not only for medicolegal defense but also for maintaining ethical
principles in patient treatment, highlighting the significance of this study's goal.[3] The standard of these records influences medical documentation and the flow of information
vital for patient care. Beyond their medical importance, the quality of operative
notes has financial and legal ramifications, making precise documentation essential
for both audits and improving the delivery of patient care.[4] According to RCSEng recommendations, operative notes should be finalized immediately
after the operation to prevent the omission of critical details and to preserve a
distinct memory of the surgery. These notes need to be clearly and methodically written
or dictated, encompassing details about the type of procedure, the surgeon's identity,
information about assistants, surgical methods, and any complications or changes from
the initial plan.[1]
[4]
[5]
[6]
In many hospitals, particularly those with scarce resources, it is customary for surgeons
to use plain, unstructured paper to document operative notes. This method often results
in records that are inconsistent and lacking in detail. The absence of standardized
formats frequently leads to the oversight of important information, which can adversely
affect patient care and weaken the legal standing of medical records. The introduction
of structured templates, as supported by the RCSEng, could significantly elevate the
quality and consistency of surgical documentation in these settings. By embracing
these templates, hospitals can make sure that all pertinent information is recorded
systematically, thus enhancing both clinical results and the strength of medical records.[7]
Recent research has emphasized how standardized documentation contributes to better
surgical results. For example, a study conducted at Dongola Teaching Hospital in Sudan
revealed that adherence to documentation rose from 50.3 to 71.9% following the implementation
of a standardized template and training for staff.[8] In a similar study, a clinical review at Doka Hospital reported a notable enhancement
in the quality of documentation, with adherence increasing from 50.5 to 82.5% after
a structured format and specific training sessions were introduced.[9] These results emphasize how effective structured measures are in improving practices
for surgical documentation. Considering the vital function of operative notes in patient
care and the proven advantages of standardized documentation, this research intends
to assess and upgrade the quality of surgical operative notes at the Ribat University
Hospital (RUH). By employing a structured methodology akin to those in earlier studies,
the aim is to boost the precision, thoroughness, and uniformity of surgical documentation,
ultimately leading to better patient outcomes and adherence to RCSEng guidelines.
Materials and Methods
Study Design and Setting
A clinical audit took place in the Department of Surgery at the RUH in Sudan, running
from August 1, 2022 to March 1, 2023. The purpose of this audit was to assess the
standard of surgical operative notes and to put measures in place to enhance how documentation
is performed.
Audit Criteria and Definitions
The quality of surgical operative notes was evaluated through an audit that centered
on three fundamental dimensions: precision, comprehensiveness, and uniformity. Precision
was gauged by the degree to which the notes accurately represented the actual surgical
event, encompassing correct details regarding instrumentation, intraoperative observations,
and any adverse events. Comprehensiveness was appraised by confirming the inclusion
of all requisite elements for thorough documentation, such as the preoperative diagnosis,
operative discoveries, performed interventions, estimated blood loss, deep vein thrombosis
(DVT) preventative measures, administration of prophylactic antibiotics, and directives
for postoperative management. Uniformity referred to the consistent nature of documentation
across various notes and practitioners, ensuring a systematic recording of all essential
information.
Audit Population and Sample Size
This study involved a detailed review of 200 surgical records. Initially, a retrospective
look at 100 notes was performed to set a benchmark for the quality of documentation
before any changes were made. Subsequently, after introducing a new standardized documentation
template and providing training to staff, another 100 notes were examined prospectively.
This second phase aimed to evaluate enhancements in how thoroughly and correctly information
was recorded. A simple random sampling technique was utilized to ensure the selection
of notes was representative of the wide variety of surgical cases handled by the department,
thus offering a dependable foundation for the audit. Notably, surgeons were kept uninformed
about the monitoring of their documentation throughout both stages of the audit, a
measure taken to reduce potential bias and capture typical clinical documentation
habits.
Data Collection and Analysis
Trained medical professionals meticulously collected data by carefully reviewing surgical
notes. They utilized a standardized checklist, based on RCSEng guidelines, which assessed
18 distinct criteria to gauge the completeness and accuracy of the recorded information.
The study began with an initial retrospective analysis of 100 randomly selected cases.
Subsequently, a second phase involved a prospective review of another 100 cases. This
second review occurred after implementing an updated documentation template (proforma)
and conducting training sessions to educate staff on correct documentation procedures.
These interventions aimed to improve the quality and uniformity of surgical records.
To evaluate the impact of these changes, the gathered data was systematically analyzed
using Microsoft Excel 2016. A descriptive analysis was performed, employing a three-zone
compliance indicator based on the scoring method detailed in [Box 1]. This analysis sought to identify and measure any enhancements in documentation
quality between the study's two phases, thereby offering insights into the effectiveness
of the revised proforma and training efforts.
Box 1
Details of the three-zone Indicators
|
The auditor utilized the subsequent scoring methodology when reviewing the record:
0 = If there is no sign that information was attempted to be documented.
1 = If insufficient information is documented.
2 = If some of the crucial details are documented.
3 = if the majority of the data are documented.
4 = if every detail of the information is documented.
n/a = if the criteria are not relevant.
|
|
This meant that, if 150 patients were audited on each cycle, each standard may result
in a score of 600. For instance, if they DVT prophylactic documented on all 150 patients,
the compliance rate would be 100% and the overall score would be 600. If 120 patients
have gotten their DVT prophylactic documented, the overall score would be 480, giving
compliance of 80%. When n/a was inputted for a standard that did not apply to any
of the patients, the spreadsheet automatically deducted 4 points from the projected
result. Prior to converting the scores into compliance rates for the hospital, the
scores for all procedures were obtained. The three-zone indication system assures
that standard with an overall compliance of 80% or higher are high, those with an
overall compliance of 50–79% are moderate, and those with an overall compliance of
less than 50% are low.
|
Abbreviation: DVT, deep vein thrombosis.
Preintervention phase (first cycle) The study's first phase involved a retrospective examination of 100 randomly chosen
surgical operative notes from the Department of Surgery.
Intervention phase To improve the identified shortcomings in documentation, a multifaceted intervention
was put in place, consisting of the three main elements outlined below:
-
Development of a standardized operation note format: A structured template, adhering
to RCSEng guidelines, replaced the previous free-form documentation method.
-
Distribution of the new template: The standardized template was shared across all
surgical departments to ensure consistent documentation of operation notes.
-
Education and training: Surgeons and surgical personnel were trained on the importance
of thorough and standardized documentation. Training approaches included a Microsoft
PowerPoint presentation during departmental meetings, focused group discussions, and
individual sessions to highlight the proper application of the new template.
Postintervention phase (second cycle) after a 4-month intervention period, the next phase of the audit began. In this stage,
100 surgical operation records from the RUH were reviewed and assessed to determine
the outcomes of the intervention. The goal was to evaluate improvements in the documentation
process and adherence to RCSEng standards.
Results
This clinical audit involved an initial review of 100 operative records, with an additional
100 records examined in a subsequent phase. The study found a substantial enhancement
in the quality of documentation across several important areas due to specific improvement
efforts.
Initially, adherence to crucial documentation standards was inconsistent. For instance,
recording of expected blood loss was recorded in (33%), DVT prevention measures were
noted in only 35 case (35%), and administration of preventive antibiotics was documented
for 41 cases (41%). Furthermore, documentation of any problems or complications occurred
in 25 records (25%).
However, after implementing strategies to improve documentation, most notably the
introduction of a standardized template aligned with RCSEng guidelines, the second
phase showed considerable progress. While staff also received training, the standardized
template was the main factor driving better completeness and accuracy in surgical
notes. For example, documentation of anticipated blood loss surged from 33 to 74%
(74 records), and recording of prophylactic antibiotic use went from 41% (41 records)
to 85% (85 records. Significant improvements were also seen in the documentation of
DVT prophylaxis, rising from 35 to 89% (89 records), and the recording of problems
or complications, which climbed from 25 to 64% (64 records).
While some aspects, like the details of the operative procedure, saw a modest rise
from 69 to 98% (29 records), and the details of closure technique saw a slight increase
from 59 to 80% (80 records), the general trend in compliance clearly points to a significant
improvement in the thoroughness of operative records (as shown in [Table 1]). Results for all standards were categorized into three-zone indicators and coded
using the system outlined in [Box 1] for all cycles. [Table 2] displays the percentage of standards that fell into each level when the results
were compiled for the RUH. This audit summary shows that compliance seems to be continuously
improving. There are now fewer low standards and more high standards. These results
underscore the success of the changes made, while also pinpointing areas that might
require further attention to ensure consistently comprehensive documentation.
Table 1
Documentation in the first and second cycles, along with the corresponding percentage
improvement
|
Documentation criteria
|
First cycle (N = 100), n (%)
|
Second cycle (N = 100), n (%)
|
Improvement (%)
|
|
Date
|
100 (100%)
|
100 (100%)
|
0%
|
|
Time
|
34 (34%)
|
90 (90%)
|
56%
|
|
Elective/emergency
|
3 (3%)
|
73 (73%)
|
70%
|
|
Name of operating surgeon
|
89 (89%)
|
100 (100%)
|
11%
|
|
Name of assistant
|
22 (22%)
|
86 (86%)
|
64%
|
|
Name of anesthesia personnel
|
5 (5%)
|
20 (20%)
|
15%
|
|
Operative procedure performed
|
69 (69%)
|
98 (98%)
|
29%
|
|
Incision
|
53 (53%)
|
74 (74%)
|
21%
|
|
Operative findings
|
47 (47%)
|
83 (83%)
|
36%
|
|
Any problems/complications
|
25 (25%)
|
64 (64%)
|
39%
|
|
Details of closure technique
|
59 (59%)
|
80 (80%)
|
21%
|
|
Anticipated blood loss
|
33 (33%)
|
74 (74%)
|
41%
|
|
Postoperative care instruction
|
100 (100%)
|
100 (100%)
|
0%
|
|
Antibiotic prophylaxis
|
41 (41%)
|
85 (85%)
|
44%
|
|
DVT prophylaxis
|
35 (35%)
|
89 (89%)
|
54%
|
|
Surgeon signature
|
17 (17%)
|
36 (36%)
|
19%
|
Abbreviation: DVT, deep vein thrombosis.
Table 2
Standards in each three-zone indicators
|
Indicator
|
Percentage of standards for August
|
Percentage of standards for March
|
|
High (80–100% compliance)
|
18.75 (3)
|
62.5 (10)
|
|
Moderate (50–79% compliance)
|
18.75 (3)
|
25 (4)
|
|
Low (<50% compliance)
|
62.5 (10)
|
12.5 (2)
|
Discussion
This audit's outcomes demonstrate considerable enhancements in the standard of surgical
records at the RUH. These improvements followed the rollout of systematic changes,
notably a standardized recording form and specific training for staff. The findings
are consistent with other research in various health care environments, which also
show that standardized documentation approaches boost the completeness and precision
of operative notes.[10]
Before these interventions, significant gaps in documentation were evident. For instance,
anticipated blood loss was never recorded (0%), DVT prevention measures were documented
in 35% of cases, use of prophylactic antibiotics in 41%, and documentation of complication
in 25%. Such omissions carry substantial clinical risks: failing to document blood
loss can lead to unmanaged bleeding during or after surgery; missing records of DVT
prophylaxis increase the danger of blood clots; incomplete antibiotic records raise
the likelihood of infections at the surgical site; and inadequate postoperative guidance
can result in poor patient recovery or mismanaged complications. These shortcomings
highlight the critical role of precise documentation in maintaining patient safety,
following clinical guidelines, and ensuring effective ongoing care. This underscores
the study's importance in tackling these deficiencies to enhance both the quality
of documentation and patient outcomes. These observations align with studies from
other low-resource areas, where the absence of standardized templates frequently results
in inconsistent and incomplete patient records.[8]
[11] The introduction of a standardized template, based on RCSEng guidelines, combined
with staff education, led to marked improvements in all measured areas. As an example,
the recording rates for expected blood loss, use of preventative antibiotics, and
after-surgery care instructions all rose to above 70% compliance after the intervention.
Similar positive changes were seen in the documentation of DVT prophylaxis (82%),
any problems or complications (73%), and additional procedures performed (94%).[9]
The effectiveness of these measures is mirrored in other studies. For example, research
at Dongola Teaching Hospital in Sudan showed that adherence to documentation norms
improved from 50.3 to 71.9% after a standardized template and staff training were
introduced.[12] Likewise, a clinical review at Doka Hospital indicated a significant rise in documentation
quality, with compliance jumping from 50.5 to 82.5% after implementing a structured
format and focused training.[9] Such studies emphasize how effective structured interventions are in upgrading surgical
documentation, particularly in settings with limited resources where nonstandardized
recording methods are common.[10]
The progress noted in this audit also corresponds with results from studies in different
regions. For instance, research at the Port Sudan Teaching Hospital reported a substantial
increase in compliance with documentation standards, from 51.9% in an initial cycle
to 82.1% in a subsequent cycle, following the use of an improved proforma and staff
education.[8] Similarly, a study at Khyber Teaching Hospital in Pakistan found that applying RCSEng
guidelines led to a distinct improvement in recording perioperative details, operative
diagnoses, and team information, with adherence rates climbing from 70.8 to 95.7%.[6] These outcomes point to the widespread applicability of standardized documentation
methods for enhancing the quality of surgical operative notes.[11]
Despite the overall advancements, some areas, like noting the anesthetist's name and
the surgeon's signature, showed only limited improvement. This is in line with findings
from other research, which have pointed out ongoing difficulties in documenting certain
details, especially in environments where traditional recording habits are firmly
established.[11]
[13] For example, a study in Wad Madani, Sudan, revealed that the anesthetist's name
was missing from all reviewed operative notes, indicating a systemic issue in documentation
habits.[11] Overcoming these specific challenges might necessitate further targeted actions,
such as incorporating electronic medical records (EMRs) and holding regular feedback
meetings to emphasize the need for thorough documentation.[12]
This audit's results also highlight the need for regular reviews and ongoing quality
improvement efforts to uphold high documentation standards. Research indicates that
continuous audits and feedback systems are essential for maintaining improvements
in documentation practices.[13] For instance, a study at the Arif Memorial Hospital in Lahore showed that regular
audits and the introduction of a redesigned proforma resulted in a 35.7% improvement
in operative note documentation.[13] Similarly, research at the Khyber Teaching Hospital demonstrated that introducing
RCSEng guidelines and regular training sessions significantly boosted the quality
of operative notes, with compliance rates increasing from 70.8 to 95.7%.[13]
In summary, the adoption of structured measures, such as standardized templates and
staff training, has considerably enhanced the quality of surgical operative notes
at the RUH. Nevertheless, ongoing work is necessary to tackle remaining challenges,
especially in recording certain details and ensuring the long-term sustainability
of these improvements. Future strategies should concentrate on integrating electronic
documentation systems, performing regular audits, and offering continuous training
to health care staff to ensure compliance with best practices in surgical documentation.[12]
The audit possesses limitations that could impact the breadth and transferability
of its conclusions. First, its exclusive focus on a single hospital raises questions
about the generalizability of the results to other health care institutions. Second,
while the study primarily aimed to evaluate the impact of introducing a new proforma,
it might not have accounted for other concurrent changes in clinical practices or
shifts in patient outcomes that could have influenced the observed results. Third,
the audit's strong reliance on quantitative data might lead to overlooking important
qualitative aspects, such as the overall richness and detail of the clinical documentation.
These constraints suggest that the findings should be interpreted cautiously and may
not fully represent the wider context or subtleties of the documentation process.
Conclusion
The implementation of a standardized operative note template, combined with targeted
staff training at the RUH, led to a notable enhancement in the quality and completeness
of surgical documentation. Critical elements such as anticipated blood loss, the use
of prophylactic antibiotics, and operative complication documentation demonstrated
significant improvement after the intervention, reflecting a more structured and thorough
approach to record-keeping. These results are consistent with existing evidence that
highlights the benefits of standardized documentation systems in low-income settings.
However, while the intervention yielded positive outcomes, some gaps in documentation
quality persisted, underscoring the need for sustained efforts to maintain and build
upon these gains. To ensure long-term adherence to best practices, it is recommended
that the hospital implement biannual audits to monitor documentation quality and identify
areas for improvement. Additionally, ongoing education programs, such as quarterly
workshops and refresher training sessions, should be established to reinforce best
practices and address emerging challenges. Exploring the integration of EMRs could
further streamline documentation processes and reduce errors. Such measures will not
only help solidify the improvements achieved but also contribute to enhancing patient
safety and the overall quality of care delivered.
Bibliographical Record
Elmuhtadibillah Babiker Yousif Gasoma, Leenah Mohammed Salih Mohammed, Ammar Alemam
Diab. Assessing and Enhancing Surgical Operative Notes in a Low-Income And Middle-Income
Country Hospital: A Model for Sustainable Improvement. Surg J (N Y) 2025; 11: a27195317.
DOI: 10.1055/a-2719-5317
