QUALITY ASSESSMENT OF SURGICAL OPERATIVE NOTES IN A TEACHING INSTITUTE: AN OBSERVATIONAL STUDY

Dr Sujay Belgod Rudramuni; Dr Yaturu Sivakumar; Dr Keerthi Mudavath; Dr Tejswaroop Pala; Dr Vellasiri Aswath Kumar; Dr Kamalakannan Thinagaran

Volume : VII, Issue : VII, July - 2018

QUALITY ASSESSMENT OF SURGICAL OPERATIVE NOTES IN A TEACHING INSTITUTE: AN OBSERVATIONAL STUDY

Dr Sujay Belgod Rudramuni, Dr Yaturu Sivakumar, Dr Keerthi Mudavath, Dr Tejswaroop Pala, Dr Vellasiri Aswath Kumar, Dr Kamalakannan Thinagaran

Abstract :

Traditionally, operative notes have been written by one of the junior members of the scrubbed team, often supervised by a senior surgeon, considered as an essential part of training. Hence the chances of deficiency are expected to be more as the residents will be in a learning curve. MATERIALS & METHODS: It was prospective observational study. A total of 200 randomly selected patients� patients� case records were studied focusing on the surgical operative notes. Surgical operative notes were analyzed with respect to 25 points checklist based on �Good Surgical Practice� guidelines.CONCLUSION: The most common missing element in the surgical operative notes was documentation of blood loss (57%) followed by details of closure technique (43.5%). There is a need for regular audit of surgical operative notes and also to periodically sensitize the surgical residents about the importance of detailed and accurate surgical operative notes.