Operative notes at surgical units of a tertiary care hospital

ABSTRACT

To assess the quality of operative notes in general surgery procedures. Descriptive study. Civil Hospital Karachi. Operative notes for all procedures were typed and saved in a data retrieval system [Health Management and Information system, DOTS'78]. A proforma was designed in accordance with the standards prescribed by Royal College of Surgeons of Edinburgh [RCSE] for taking down surgical case notes. The operative notes were studied and a proforma was filled for each. These were then compared with the prescribed standard for completion of documentation. The data was analyzed on SPSS 13. Out of a total of 100 notes, 99 had operating surgeons name mentioned, however, the time of surgery was missing in all. Approximately half of the notes surveyed did not mention the incision type, while operative diagnosis was mentioned in 92% of the notes. Post operative instructions were mentioned in 89% of the notes reviewed. Standardized notes documentation was not found in the present study in most of the cases