The quality of operation notes after trans-urethral resection of the prostate at Kilimanjaro Christian Medical University College Hospital Tanzania

Abstract

Background: Operation notes are very vital in the practice of surgery. They are the only comprehensive account of what took place in theatre. Accurate and detailed documentation of surgical notes after Transurethral Resection of the Prostate (TURP) is vital. Yet it is usually forgotten in medical teaching. The Royal College of Surgeons of England (RCSE) safety standards are usually used as the benchmark for the assessment of operation notes.

Patients and Methods: The study was descriptive retrospective conducted at Kilimanjaro Christian Medical Centre (KCMC). All patients who underwent TURP between January and December 2017 were enrolled. The Urology theatre register was used to trace patient identities. The Files were then extracted from the registry. Operation note sheets were analysed by the research team using a structured data collection tool. Two Independent assessors(residents) were used to assess legibility. If both agreed that the notes were decipherable, then they were deemed legible. The content of the notes was assessed for Presence or absence of recorded variables. Utmost confidentiality was kept about the surgeon and the patient.

Results: A total of 251 files were assessed. Recording of date, Inpatient number, Post-Operative instructions and whether there were any intraoperative complications was at 100%. However, the time of surgery, Resection technique and Method of introduction of the resectoscope were not recorded at all. Other variables recorded were: Signature of surgeon -99.6%, Patient name-99.6%, Details of prostate chips-89%, Sheath used-81%, Circulating nurse-68%, Working element used-35%, Telescope used-12%, Type of diarthermy-7%, Loop Specifications-0.8% and type of Irrigant at 0.8%. Ninety-eight percent of the  operation notes were legible. Overall 56.6% of the operation notes had recorded variables after TURP.

Conclusion: Some variables (Inpatient number, Date of operation, intraoperative complications and Postoperative instructions) were recorded at 100%. Others (Time of operation, Resection technique and method of introduction of resectoscope) were not recorded at all. Overall 56.6% of the variables were recorded and 98% of the notes were legible.