The quality of operation theatre notes in the orthopaedic department of Kenyatta National Hospital

Abstract

Background: Well written theatre operation notes are important not only as a medico legal requirement but also useful for clinical research. This study assessed the quality of orthopaedic theatre notes at Kenyatta National Hospital, the largest referral facility in Kenya, over a 6-month period between January 2017 and June 2017.
Objective: To determine the completeness and clarity of operation theatre notes in The Orthopaedic Department of Kenyatta National Hospital.
Patients and methods: Operation theatre notes in the orthopaedic unit 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. One hundred and eighty seven (87%) of the theatre notes were written by an orthopaedic resident, only 24 (13%) cases were written by the consultant. One case had no theatre notes written. Documentation was especially good for name of operating surgeon (97%), name of assistant (90%) and anaesthetist (97%) type of procedure (96%), patient biodata (95%), date
of surgery (91%) and preoperative diagnosis (97%). The documentation was poor in swab/instrument count (0.5%), use of tourniquets (40/167, 23%) identifying the time of surgery (23%), estimating blood loss (25%), complications encountered if any (30%) and closure technique (47%).
Conclusion: The quality of operation theatre notes in The Department of Orthopaedic Surgery is good but improvements should be made especially on recording swab/instrument count, implant serial numbers, details of closure technique and use of tourniquets. Use of a standardized checklist may improve quality of operation theatre notes in our hospital.

Key words: Quality, Operation Notes, Orthopaedic, Guidelines