Clinical audit of operation notes at the Department of Surgery, Addis Ababa University
Abstract
Introduction: Operation notes document the key findings and details of a surgical procedure, and are critical to its safety. The Royal College of Surgeons of England has set an internationally-accepted standard for elements of a quality operative note, but no prior research has considered conformity of Ethiopian teaching hospitals with these standards.
Methods: A cross-sectional sample was collected at two Addis Ababa University teaching hospitals: Menelik II Referral Hospital and Tikur Anbessa Specialized Hospital (TASH). Patients admitted and operated in the period between August 1st and October 31st, 2017 were analyzed with respect to 2014 RCSE best practice guidelines.
Results: All notes (n=348) were handwritten. Documentation of operative findings, anesthesia, patient position, and incision type were (>90%) at both hospitals. Residents wrote 98% of Menelik and 91% of TASH documents. Surgeons and assistants were identified in (>96%) of notes from Menelik and TASH, while (88.5%) identified the anesthesia team at Menelik and (5.7%) at TASH. Gauze and instrument counts were documented in (81.2%) from Menelik and (69.5%) at TASH. Closure technique was described in (71.8%) from Menelik and (52.3%) from TASH. Operation note templates did not include effective antibiotic prophylaxis, DVT prophylaxis, and estimated blood loss at both hospitals.
Conclusion: Operation notes in the studied hospitals were both grossly incomplete and below the standards as described by RCSE guidelines, with specific concerns being insufficient documentation of technique and support staff, and missing documentation of prophylaxis and blood loss. Completion of the audit cycle recommends AAU implement a new operation note format incorporating RCSE requirements, increase supervision of senior surgeons in note taking, and improve surgical documentation training in the residency curriculum.
