QUALITY OF OPERATIVE NOTES

Objective: To evaluate the quality of written operative notes of patients undergoing surgery in a tertiary care teaching hospital.Material and Methods: It is a retrospective audit carried out in the department of surgery, unit II at Civil Hospital, Karachi over a period of three months from July to September, 2007. Randomly selected operative notes were assessed according to published guidelines of the Royal College of Surgeons in Ireland (Good Surgical Practice, 2004).Results: Out of 185 operative notes analysed, 160 (86.5%) were written by the trainee surgeons, 24 (13%) by house officer and only one (0.5%) by consultant. The type of the operation was recorded in 181 (97.8%) of the operative notes, patientʹs identification in 115 (62.2%), type of incision in 163 (88.1%) and operative findings in 177 (95.7%). Operative complications were mentioned in only 30 (16.2%) of notes. Post-operative orders were recorded in 184 (99.5%) and abbreviations were used in 83 (44.9%) of notes. Only three notes did not have a signature of the person writing the notes. Legibility of the notes was assessed to be good in 155 (83.8%), fair in 20 (10.8%) and poor in 10 (5.4%).Conclusion: Most of the operative notes were written by the junior members of the operating team who did not have the sufficient knowledge and skill. This was evident since some critical details were missing in the notes.