A comparison of the quality of operation theatre notes written by the orthopaedic resident and the consultant orthopaedic surgeon

Abstract

Background: Theatre operation notes are an important documentation that impact on patient care and are a very useful record for clinical research and are a medico-legal requirement.
Objective: To compare the quality of operation theatre notes of the orthopaedic resident and the orthopaedic consultant.
Patients and methods: Operation theatre notes in the orthopaedic unit of Kenyatta National Hospital, over a 6-month period between January 2017 and June 2017 were retrospectively analysed. The guidelines of the Royal College of Surgeons of England (RCSEng) were used to assess the quality of operation notes.
Results: A total of 211 orthopaedic operation notes were reviewed. 187 (87%) of the theatre notes were written by an orthopaedic resident and 24 (13%) cases were written by the consultant. The quality of the operation theatre notes written by both were generally similar. However, the consultant surgeon had better details of operation theatre notes in some aspects especially information involving type of surgery, time, patient  name and biodata, name of the operating surgeon and assistant, procedure carried out, patient position, operative findings, prosthesis identification, closure techniques and details of use of tourniquet where there was statistical significance (p value <0.05).
Conclusion: The quality of operation theatre notes written by the orthopaedic resident is generally similar to the consultant orthopaedic surgeon but the consultant notes were better in many aspects. There is thus need for consultant surgeons to train their residents in writing good quality theatre operation notes.