An audit of the quality of surgical operation notes in a Nigerian teaching hospital

Abstract

Background: Operation note records are important tools for ensuring patients’ continuity of care, for research purposes and medico-legal reasons. They can effectively serve these purposes only if well documented. The main objective of this study was to assess the practice of recording the operation notes among surgical trainees in a Nigerian Teaching Hospital.

Methods: Operation notes completed by doctors in the Surgery Department over a 2-month period were audited for completeness, legibility and conformity to the standards of the Royal College of Surgeons of England.

Results: There were 100 operation notes reviewed, two-thirds of these were written by Senior Registrars, majority of which were for elective operations (63%). Only 37 of the operation notes were appropriately completed with about two-thirds either incomplete or wrongly filled. The cadre of the surgical trainee did not significantly influence the completeness of the operation notes.  Legibility of the operation notes was associated significantly with completeness (p<0.04).  

Conclusion: Standards of operation note writing in our practice needs to be improved upon. The challenges of legibility and completeness of documentation can be overcome by the use of an aide-memoire as well as computerized operation notes.