1. Audit of the quality of operation notes in Gynecology Department of Obstetrics and Gynecology and Department of Medical Education Era’s Lucknow Medical College, Lucknow (UP) INDIA Prof.Uma Gupta Prof K.Srivastava Prof.N.K.Gupta

2. Introduction With icreasing litigations accurate documentation is critical. Maintaining a full & and proper record –OT notes is responsibility of every surgeon. Medical councils have identified this and published guidelines to aid surgeons.

3. Aim: Aim of this study was to assess accuracy of operative notes in a gynecological unit and improve practices.

4. Methods: An audit of recording gynecological operative notes was carried at ELMC Lucknow. An audit of consecutive operation notes for 3 months & 100 retrospective operation notes was done. The quality of operation record in 180 case notes was assessed. As per RCS guidelines, a questionnaire of good operative notes was framed.

5. Contd…..Methods: Case notes were evaluated against these standards. Legibility and ability to comprehend operative details was also assessed. Statistical analysis done by package of SPSS 10.0.

6. Audit of the quality of operation notes in Gynecology Surgeon Consultant/ Senior Resident/ JRII Surgeon Name of operationYes /No Date of operationYes /No Time of operationYes /No Patient’s ID notedYes /No Surgeon’s nameYes /No Surgical Asst 1Yes /No Nursing AsstYes /No Anaesthetist TeamYes /No Type of anaesthesiaYes /No DiagnosisYes /No IncisionYes /No Operative findingsYes /No Operative complicationsYes /No ClosureYes /No Total time takenYes /No Postoperative instructionYes /No Counts takenYes /No HPR record (Tissue)Yes/No SignatureYes /No 100% LegibilityYes /No

7. RESULTS There was 72.27% compliance rate for 23 parameters by 180 persons. 100% was achieved for 5 operation sheets. The compliance: patient's name not on operation notes page (93.33%), hospital number absent in (93%), every entry timed (68.3%), clinician's name written on every note except in (1.6%), each entry legible (96.7%), and anaesthetist's name (74.5%),operative finding and final diagnosis mentioned in 68.9% and 65.6% respectively.

8. Observations Consultant- 6.6% Sr Resident-36.3% JRII - 57.2%

9. Bars showing responses on patient ID,time and date of operation (n=180) 168/180(93.33%) where having no name /patient id 15/180(8.3%) did not mention date 123(68.3%) mentioned time

10. Observations Mention of time of operation Yes=Mentioned Consultant- 58.3% Sr Resident-80% JRII - 62.1%

11. Figure showing mention of name of surgeon, asst name, anesthetist, type or anesthesia and nursing asst. n=180 156(86.6%) no mention of nursing OT assistant 46(25.5%) no mention of name of anesthetic team 1.6% no surgeon name 5% asst name missing

12. Assistant’s nameNursing assistant’s name 156(86.6%) no mention of nursing OT assistant 5% asst name missing

13. Anesthetist’s name n-180 46(25.5%) no mention of name of anesthetic team Yes=Mentioned Consultant- 75% Sr Resident-75.4% JRII - 73.8%

14. Yes=Mentioned Consultant- 75% Sr Resident- 75.4% JRII - 73.8%

15. Figure showing mention of diagnosis, operative finding, final diagnosis, operative complication if any & closure. n=180

16. Operative findings YES=Mentioned Consultant – 100% Sr.Resident – 70.7% JRII - 64%

17. Figure showing mention of time taken, counts taken, histopathology sent, signature and legibility. n=180

18. Time taken for surgery Yes=Mentioned Consultant- 75% Sr Resident-75.4% JRII - 73.8%

19. Counts and beginning and end Yes=Mentioned Consultant- 75% Sr Resident-75.4% JRII - 73.8%

20. Bar diagram showing consent

21. Consent details 1-9% JR2 did not take consent properly

22. Summary There was 72.27% compliance rate for 23 parameters by 180 persons. 100% was achieved for 5 operation sheets. The compliance: patient's name not on operation notes page (93.33%), hospital number absent in (93%),

23. Discussion Shayah et al(2007)in 1st cycle results showed the documentation of patient identification (94%), name of surgeon (98%) and clearly written postoperative instructions (94%). However, surgeons performed suboptimally at recording the name of assistant (82%), operative diagnosis (46%), the incision type (87%) and the type of wound closure (83%). Int J Clin Pract. 2007 Apr;61(4):677-9.)

24. Discussion Mathews et al(2003)observed - time of the operation was recorded in 6% of the operative notes written by the consultants and 16% of the notes recorded by the registrars.Patient's identification was not noted by 6% of consultant's and 10% of notes entered by the registrars. 19% of the consultant's notes did not mention the type of incision. The Internet Journal of Surgery 2003 : Volume 5 Number 1)

25. Discussion : There was an 80% compliance rate for 16/35 standards, and 100% was achieved for 8 operation sheet standards. S Afr J Surg. 2007 Aug;45(3):92, 94-5.

26. Conclusions This study identified areas of weakness in operative note-keeping. Proformas should be introduced for commonly performed procedures. Restructuring operation notes sheet with all parameters to constantly remind entries could be a step towards improvement

27. Conclusions Legal requirements, good practice, research and teaching all demand notes that are detailed and of high quality. Better education of junior staff and regular auditing of medical records could improve this. All clinical departments and hospitals should carry out detailed studies into the contents of their medical notes, and suggest changes and reaudit.