ABSTRACT
Background: Proper documentation of the surgery done in the form of operative notes is a very important aspect of surgical practice. The aim of this clinical audit was to identify the existing standard of the operative notes written in a general surgical unit in a quaternary care hospital; and to compare it with the recommendations given by Royal College of Surgeons, England (in Good Surgical Practice, 2014) and if needed, to improve the standard of practice.Methods: In the first loop of this prospective audit, 75 consecutive operative notes which were written were compared with the RCS guidelines and the areas which had missing data were identified. These areas were informed to the residents, who are primarily involved in the documentation of the operative notes. The second loop of the audit was conducted after a gap of 4 months involving 75 consecutive operative notes again.Results: The areas which were initially deficient were better documented when analysed in the second loop.Conclusions: Documentation of operative notes does not always comply with the set guidelines as highlighted in the first loop of our audit. But by employing a clinical audit it is possible to identify the existing deficiencies and thereby improving the standards of practice. Also, operative note writing should be taught as part of surgical training. Definitions should be clearly provided, and specific guidelines should be established to improve the quality of the operative notes and their use to improve patient safety.
ABSTRACT
Background: With teleneurosurgery, more patients with head injury are managed in the primary hospital under the care of general surgical unit. Growing concerns regarding the safety and outcome of these patients are valid and need to be addressed.Method: This study is to evaluate the outcome of patients with mild head injury which were managed in non-neurosurgical centres with the help of teleneurosurgery. The study recruits samples from five primary hospitals utilising teleneurosurgery for neurosurgical consultations in managing mild head injury cases in Johor state. Two main outcomes were noted; favourable and unfavourable, with a follow up review of the Glasgow Outcome Scale (GOS) at 3 and 6 months.Results: Total of 359 samples were recruited with a total of 11 (3.06%) patients have an unfavourable. no significant difference in GOS at 3 and 6 months for patient in the unfavourable group (P = 0.368).Conclusion: In this study we have found no significant factors affecting the outcome of mild head injury patients managed in non-neurosurgical centres in Johor state using the help of teleneurosurgery.