The Importance of Accurate Operation Notes

The importance of accurate, legible, and detailed operation notes cannot be understated for all practicing surgeons. This is essential for clear communication between the peri-operative and post-operative periods, contributing to improved patient care and safety. Furthermore, it serves as a beneficial tool for research, audit, and medicolegal purposes.

The Royal College of Surgeons of England (RCS) Good Surgical Practice guidance identifies essential criteria for surgical operation note documentation. The current quality improvement project aims to identify if using pre-templated operation notes for documenting fractured neck of femur surgery results in improved documentation when compared to freehand orthopaedic operation notes.

A total of 14 categories were identified from the RCS guidance as required across all the operations identified in this study. All operations for one month were identified and the operation notes analysed. Pre-templated operation notes were compared to freehand operation notes.

Key Observations of the Study

• 97 cases were identified, of which 74 were freehand operation notes and 23 were pre-templated fractured neck of femur operation notes.
• All 14 categories were completed in 13 (57%) of the templated operation notes versus 0 (0%) in the freehand operation notes (odds ratio 0.0052, 95% CI 0.0003 to 0.0945, p< 0.001).
• The median total number of completed categories was significantly higher in the templated op-note group compared to the freehand op-note group (templated median 14, range 12–14, vs. freehand median 11, range 9 to 13, p< 0.001).
• Logistic regression analysis of operation notes written by consultants or trainees identified trainees as more likely to document the antibiotic prophylaxis given (p=0.025).

The authors concluded that – “Use of pre-templated operation notes results in significantly improved documentation. Adoption of generic pre-templated operation notes to improve surgical documentation should be considered across all operations.”

“We acknowledge that this study is limited with regards to being retrospective, only including cases from a single-centre and pre-templated operation notes only being used for cases related to NOF Fractures. Although we would argue these results are significant enough to recommend the use of pre-templated operation notes, further research could focus on development of a general template for use when documenting all operations. This would allow a prospective study comparing pre-templated operation notes to freehand, without the limitations of this study,” the authors commented.

Further Reading

Orthopaedic surgical documentation: pre-templated operation notes significantly improve documentation of surgical procedures by Fraser Sneddon, N. Fritsch et al. Journal of Orthopaedic Surgery and Research (2023) 18:48. https://doi.org/10.1186/s13018-022-03484-9