Orthopaedic surgical documentation: pre-templated operation notes significantly improve documentation of surgical procedures.

OBJECTIVES

The Royal College of Surgeons of England (RCS) Good Surgical Practice guidance identifies essential criteria for surgical operation note documentation. The current quality improvement project aims to identify if using pre-templated operation notes for documenting fractured neck of femur surgery results in improved documentation when compared to freehand orthopaedic operation notes.

METHODS

A total of fourteen categories were identified from the RCS guidance as required across all the operations identified in this study. All operations for the month of October 2021 were identified and the operation notes analysed. Pre-templated operation notes were compared to freehand operation notes.

RESULTS

Ninety-seven cases were identified, of which 74 were freehand operation notes and 23 were pre-templated fractured neck of femur operation notes. All fourteen categories were completed in 13 (57%) of the templated operation notes versus 0 (0%) in the freehand operation notes (odds ratio 0.0052, 95% CI 0.0003 to 0.0945, p < 0.001). The median total number of completed categories was significantly higher in the templated op-note group compared to the freehand op-note group (templated median 14, range 12-14, vs. freehand median 11, range 9 to 13, p < 0.001). Logistic regression analysis of operation notes written by consultants or trainees identified trainees as more likely to document the antibiotic prophylaxis given (p = 0.025).

CONCLUSIONS

Use of pre-templated operation notes results in significantly improved documentation. Adoption of generic pre-templated operation notes to improve surgical documentation should be considered across all operations.