Quality of operation notes following orthopaedic procedures in a tertiary centre: A need for re-orientation

Abstract

Background: Operation notes are as important as the operation because healing conceals operative details that radiographs may not distinguish such as surgical approach to a fracture site. Clarity of documentation is essential for good record keeping, audit, follow-up and medico-legal defense.
Method: This study evaluated the details in operation notes written in a tertiary centre in the Midwest of Nigeria by consultants and senior residents in orthopaedic surgery in order to ascertain how detailed they were.
Results: It showed lack of details in the operation notes regardless of the cadre of the surgeon.
Conclusions: We conclude that a clearly written standard protocol for writing operation notes or electronic recording of operative notes in developing countries will prevent such glaring lapses in operation notes and will be useful for research, training and defense against medico-legal suits.

Keywords: Operation notes; orthopaedic procedures; adequate details; customized stationary.