RESUMEN
Background : A comprehensive, thorough, accurate, legible and professional operative note allows seamless and proper transfer of patient care from the operating table to the postoperative care room and beyond. Further, incomplete and illegible handwritten operative notes in medico legal cases may be an Achilles heel in the surgeon’s defense. Aims : This study audited the quality of operative note keeping of general surgical procedures against the standards set by the Royal College of Surgeons of England (RCSE) guidelines. The aim of the study was to assess the compliance while also improving record keeping, documentation, the quality of operative notes, and educating surgery residents. Materials and Methods : The information from operative notes of every patient undergoing general surgical procedures was collected over a period of seven months. The data was formulated and analyzed using the SPSS version 20. Results : Total of 560 operative notes were recruited and audited. All the notes were hand-written, with the majority being written by postgraduate residents (86%).The postoperative care advice, fluid and antibiotic instructions were documented in the finest manner (100%). However, only 1% of the notes mentioned the Patients’ name, Gender and Age. All operative notes (>99 percent) included the names of the operative surgeon and assistants. The consultant in charge was documented in only 12 percent emergency notes and 100 percent elective procedures. The name of runners (Nursing Orderly) was missing from all the notes. Notably, no details of closure techniques were mentioned in any of the operative notes. Almost all of the operative notes were not signed properly to include the resident’s name and code. Conclusion : The quality of the operation notes that were entered into the patient’s case sheets was poor and insufficient, and it needed to be greatly improved. The findings of the study underline the necessity for residents to receive mandatory training on data collection and how to produce operative notes according to institutional