IJSR International Journal of Scientific Research 2277 - 8179 Indian Society for Health and Advanced Research ijsr-7-7-16198 Original Research Paper QUALITY ASSESSMENT OF SURGICAL OPERATIVE NOTES IN A TEACHING INSTITUTE: AN OBSERVATIONAL STUDY Sujay Belgod Rudramuni Dr. Dr Keerthi Mudavath Dr. Dr Vellasiri Aswath Kumar Dr. July 2018 7 7 01 02 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.