- Email: [email protected]
Improving the quality of operation notes: Effect of using proforma, audit and education sessions
+
MODEL
Asian Journal of Surgery xxx (xxxx) xxx
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.e-asianjournalsurgery.com
ORIGINAL ARTICLE
Improving the quality of operation notes: Effect of using proforma, audit and education sessions Osman Bozbiyik*, Ozer Makay, Murat Ozdemir, Berk Goktepe, Sinan Ersin Ege University School of Medicine, Department of Surgery, Turkey Received 6 August 2019; received in revised form 22 September 2019; accepted 1 October 2019
KEYWORDS Data reporting; Medical audit; Surgical operation notes
Summary Background: Both from a medical and legal point of view, the quality of operative notes are important. In this study we hypothesized that the quality of operation notes could be improved by audit, education session and using a proforma. Methods: A total of 150 operation notes were audited for compliance with the Royal College of Surgeons guidelines. Results were announced in-clinic training session and guidelines were discussed. An aide-memoire containing guideline parameters placed in the operating theaters. After eight months, operation reports were re-audited on an equal number of patients. An operative note proforma was developed and third audit was carried out. The results of each audit were compared. Results: In the first audit, it was found that fourteen parameters were written with more than 90% accuracy. The first audit revealed seven poor areas in documentation: time of operation (0%), identification of emergency/elective procedure (0%), identification of any prosthesis or devices used (65.3%), details of closure technique (36.6%), name of anesthesiologist (0%), patient position (1.3%), and amount of bleeding (0%). In the second audit there was an incomplete, but significant improvement in these seven parameters (28%, 28.6%, 82%, 75.3%, 31.3%, 32%, and 34% respectively). Following introduction of the proforma; third audit cycle demonstrated a clear improvement in operation note documentation with at least 80% compliance in all parameters. Conclusion: This study revealed that the accuracy of the operating room documents can be improved through audits, education of surgeon and using proformas. The use of proforma provides much better results. ª 2019 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
* Corresponding author. Ege Universitesi Tıp Faku ¨ltesi Hastanesi, Genel Cerrahi, Bornova, Izmir, 35100, Turkey. Fax: þ90 232 339 88 38. E-mail address: [email protected] (O. Bozbiyik). https://doi.org/10.1016/j.asjsur.2019.10.002 1015-9584/ª 2019 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Please cite this article as: Bozbiyik O et al., Improving the quality of operation notes: Effect of using proforma, audit and education sessions, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.10.002
+
MODEL
2
O. Bozbiyik et al.
1. Introduction Clinical record keeping is an integral component in the delivery of quality healthcare.1 Both from a medical and legal point of view, the quality of operative notes are important. It should enhance communication between different healthcare professionals.2 Well-documented records can be useful for care of the patients, medical research and long-term follow-up.3 Neither in textbooks nor in literature there is not enough information about how to write a standard operation note. Royal College of Surgeons (RCS) Guidelines have identified eighteen criteria of operation note documentation for “Good Surgical Practice”.4 These criteria are: patient name, date of birth, hospital number, date of operation, time of operation, elective/emergency procedure, name of the operating surgeon, name of operating assistant, name of operation, the incision, operative findings/diagnosis, intra-operative complications, any extra procedure performed and the reason why it was performed, details of tissue removed, added or altered, identification of any prosthesis or devices used, details of closure technique, post-operative care instructions, and signature of surgeon. In this study, we hypothesized that the quality of operation notes could be improved by audit, educational sessions and using a proforma, including RCS Guideline criteria.
2. Methods We carried out a prospective audit on operation note documentation at Ege University Hospital, Department of Surgery over a four week period in April 2016. Notes were analyzed and reviewed for completeness. In the first audit, 150 operation notes were audited for compliance with eighteen criteria of the Royal College of Surgeons ‘Good Surgical Practice’ Guidelines. Seven additional criteria were also included. These additional criteria are:
name of anesthesiologist name of operating nurse type of anesthesia patient position side of operation (right/left) diagnosis after operation amount of bleeding
One hundred fifty operation notes were consecutively and randomly selected from upper gastrointestinal surgery (n Z 50), endocrine surgery (n Z 50) and emergency surgery (n Z 50). Equal number of notes was reviewed from each surgical subspecialty in each audit. Following the first audit, results were announced in an in-clinic training session and guidelines were discussed. An aide-memoire containing guideline parameters was placed in the operating theaters. After eight months on December 2016, one hundred fifty operation reports were re-audited on an equal number of patients from each surgical subspecility (upper gastrointestinal surgery (n Z 50), endocrine surgery (n Z 50) and emergency surgery (n Z 50)). After second audit cycle, a computerized operative note
proforma including the RCS Guideline criterias was developed and introduced into practice in January 2019. The audit was repeated over a four week period in June 2019. Again one hundred fifty operation notes were randomly selected from same surgical subspecialties (upper gastrointestinal surgery (n Z 50), endocrine surgery (n Z 50) and emergency surgery (n Z 50)). All of the operation notes were written by trainees (chief residents) or attending surgeons on electronic medical record system. It was not possible to fulfill all criteria in one operation. Terms were evaluated in the broadest sense as much as possible In the third audit, It was easy to evaluate because each criterion had a gap. In the first and second audits we evaluated the criteria in the broadest sense. If ‘midline’ is written for side of operation, we have accepted that as correct. While evaluating the ‘Any protesis and devices used’ criterion, in thyroid surgery, it was checked whether the energy device used or neuromonitoring device was written or not. Similarly, in the gastrointestinal system surgery, staplers used were expected to be written. Although each criterion is not suitable for all types of surgery, we have accepted that it is correctly written if it is not possible to fulfill those criteria.
2.1. Brief summary of procedures to improve the quality of the surgical report After the first audit, the results of the audit were presented to the surgeons and an education was given on the parameters that the surgical notes should contain. An aide memoire card was printed to remind surgeons about the Royal College of Surgeons guidelines, and hanged at operation room’s computer terminal. After the second audit, the results of first and second audit presented to surgeons and again an education was held. Beside this, operative note proforma including criterias was developed and proforma was installed on operating room computers and surgeons were provided to use. All statistical analysis was performed using SPSS (version 25.0; SPSS Inc, Chicago, IL) The results of each audit were compared and statistically analyzed using Cochran’s Q test for each standard. McNemar’s test is used to compare two audits (audit 1 vs audit 2 and audit 2 vs audit 3). A p value of <0.05 was considered statistically significant.
3. Results A total of 450 operation notes were reviewed, involving 150 operation notes in each audit cycle. Operations ranged from simple drainage of abscesses to complex laparoscopic cancer surgery. In the first audit, it was found that eighteen parameters were written with more than 90% accuracy. The first audit revealed seven poor areas in documentation of time of operation (n Z 0), emergency/elective procedure (n Z 0), identification of any prosthesis or devices used (n Z 98, 65%), details of closure technique (n Z 55, 37%), name of anesthesiologist (n Z 0), patient position (n Z 2, 1%), and amount of bleeding (n Z 0). In the second audit there was an incomplete, but significant improvement in these seven parameters (28%, 28.6%, 82%, 75.3%, 31.3%, 32%, and 34%
Please cite this article as: Bozbiyik O et al., Improving the quality of operation notes: Effect of using proforma, audit and education sessions, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.10.002
+
MODEL
Improving the quality of operation notes
3
respectively) (Fig. 1). Following introduction of the proforma; third audit cycle demonstrated a clear improvement in operation note documentation with at least 80% compliance in all parameters (Table 1).
4. Discussion Detailed and accurate writing of surgical note is important in quality based patient management. Nevertheless, this issue has not been adequately addressed in textbooks and literature. The RCS Guidelines, published in 2008, outlined eighteen criteria that should have been in a surgical operation note.4 Previous studies have assessed quality of operation notes according to RCS guidelines and described different methods to improve the quality of operation notes.2e7 In this study, the quality of operation notes increased with education, supervision and using proformas. It is known that use of electronic databases and proformas are important to increase the quality of operation notes.8,9 Despite the use of electronic medical record system in our hospital, our first audit revealed that four parameters of RCS guidelines and additional three parameters were insufficient. Similar to previous studies, this study demonstrated that documentation in operation notes was generally poor.6e10 Therefore, an education session was held and an aide-memoire containing guideline parameters was placed in the operating theaters. After waiting for a reasonable period for adaption, during the second audit we found out that these seven parameters moderately improved. Nevertheless, dissimilar to studies in the
100
93.3
94.6
91.3
91.3
88.6
90
82
83.3
80.6 75.3
80 65.3
70 60 50
36.6
40
34
32
31.3
28.6
28
30
First Audit (%) Second Audit (%) Third Audit (%)
20 10 0
0
0
1.3
0
0
Figure 1 Table 1
Significantly improving seven parameters.
literature, this improvement was not sufficient. The use of aide-memoire containing guideline parameters to increase the quality of surgical notes is known, but they were not sufficient in our study.9,11 It is not easy to recover a habit that has been settled for a long time. Some parameters, which are not recorded to operation note by the surgeon, are recorded to other forms by operating room nurse or anesthesiologist.10 For example, parameters such as antibiotic prophylaxis, amount of blood used, duration of surgery are documented by the anesthesiologist on intraoperative anesthesia charts. However, it would be a good practice to document them in the operation note for clarity and ease of access. In our medical report system some datas like date of operation, operating surgeon, operating assistant, operating nurse, type of anesthesia, name of operation have special boxes. We have noticed that datas which have boxes to be filled has been written at a higher rate. So we prepared an operative note proforma, including RCS criteria. In this study, after introducing an operative note proforma, third cycle audit resulted in a significant improvement in the quality of the reports. Using proforma is a cheap and easy method of improving the quality of medical records.5 In this paper, we put forward further evidence of using operation note proforma is more effective than education session and using aide-memoir in operation theaters. This is easy to understand, because it is much easier to fill gaps in proforma. We would strongly recommend that each surgical deparment regularly audits its practice and uses a simple proforma. It is considered necessary to use a clear and complete note to prevent unnecessary delays or errors in management during post-operative period.9,10 It is difficult to evaluate whether improvement of operation note quality actually leads to superior patient outcomes. This is a common limitation to studies aiming to improve operation note quality. Further studies are needed whether high quality surgical notes improve patient outcomes. One of the limitations of this study is lack of equal time between audits. At the beginning, this research was planned as a two-step study. But when the increase in the quality of the surgical report was not sufficient, a third step including operation note proforma was planned. Additional time is required to prepare proforma and introduce into practice. This study revealed that the accuracy of the operating room documents can be improved through audits,
Comparison of parameters showing improvement in compliance.
Time of operation Emergency/elective procedure Identification of any prosthesis& devices used Details of closure technique Name of anesthesiologist Patient position Amount of bleeding
First Audit (n:150)
Second Audit (n:150)
Third Audit (n:150)
p (*)
0 0 98
42 43 123
140 137 137
0.001 0.001 0.001
55 0 2 0
113 47 48 51
142 121 125 137
0.001 0.001 0.001 0.001
p(c) (1st &2nd)
p(c) (2nd &3rd)
0.001
<0.001 0.001 0.001
0.001 0.001
0.001 0.001 <0.001 <0.001
(*): Cochran Q test, (c): Mc Nemar Test.
Please cite this article as: Bozbiyik O et al., Improving the quality of operation notes: Effect of using proforma, audit and education sessions, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.10.002
+
MODEL
4
O. Bozbiyik et al.
education of surgeon and using proformas. The use of proforma provides much better results. In conclusion, effectiveness of a combination of education and operative note proforma was shown.
5.
Funding
6.
The study was not funded by any organization.
Declaration of Competing Interest The authors have no conflicts of interest to declare.
7.
8.
References 9. 1. Mathioudakis A, Rousalova I, Gagnat AA, Saad N, Hardavella G. How to keep good clinical records. Breathe. 2016;12:371e375. 2. Ma GW, Pooni A, Forbes SS, et al. Quality of inguinal hernia operative reports: room for improvement. Can J Surg. 2013;56: 393e397. 3. Ahearn N, Barbur S, Barksfield R, et al. Assessing the quality of operation notes: a review of 1092 operation notes in 9 UK hospitals. Patient Saf Surg. 2016;10:5. 4. Royal College of Surgeons. Good surgical practice section 1.3. www.rcseng.ac.uk/-/media/files/rcs/standards-and-
10.
11.
research/gsp/gsp-2014-web.pdf?laZen; 2014. Accessed March 1, 2019. Payne K, Jones K, Dickenson A. Improving the standard of operative notes within an oral and maxillofacial surgery department, using an operative note proforma. J Maxillofac Surg. 2011;10:203e208. Scherer R, Zhu Q, Langenberg P, Feldon S, Kelman S, Dickersin K. Comparison of information obtained by operative note abstraction with that recorded on a standardized data collection form. Surgery. 2003;133:324e330. Din R, Jena D, Muddu BN. The use of an aide-memoire to improve the quality of operation notes in an orthopaedic unit. Ann R Coll Surg Engl. 2001;83:319e320. Laflamme MR, Dexter PR, Graham MF, Hui SL, McDonald CJ. Efficiency, comprehensiveness and cost-effectiveness when comparing dictation and electronic templates for operative reports. AMIA Annu. Symp. Proc. 2005;2005:425e429. Singh R, Chauhan R, Anwar S. Improving the quality of general surgical operation notes in accordance with the Royal College of Surgeons guidelines: a prospective completed audit loop study. J Eval Clin Pract. 2012;18:578e580. Parwaiz H, Perera R, Creamer J, Macdonald H, Hunter I. Improving documentation in surgical operation notes. Br J Hosp Med. 2017;78:104e107. Shayah A1, Agada FO, Gunasekaran S, Jassar P, England RJ. The quality of operative note taking: an audit using the Royal College of Surgeons Guidelines as the gold standard. Int J Clin Pract. 2007;61:677e679.
Please cite this article as: Bozbiyik O et al., Improving the quality of operation notes: Effect of using proforma, audit and education sessions, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.10.002
MODEL
Asian Journal of Surgery xxx (xxxx) xxx
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.e-asianjournalsurgery.com
ORIGINAL ARTICLE
Improving the quality of operation notes: Effect of using proforma, audit and education sessions Osman Bozbiyik*, Ozer Makay, Murat Ozdemir, Berk Goktepe, Sinan Ersin Ege University School of Medicine, Department of Surgery, Turkey Received 6 August 2019; received in revised form 22 September 2019; accepted 1 October 2019
KEYWORDS Data reporting; Medical audit; Surgical operation notes
Summary Background: Both from a medical and legal point of view, the quality of operative notes are important. In this study we hypothesized that the quality of operation notes could be improved by audit, education session and using a proforma. Methods: A total of 150 operation notes were audited for compliance with the Royal College of Surgeons guidelines. Results were announced in-clinic training session and guidelines were discussed. An aide-memoire containing guideline parameters placed in the operating theaters. After eight months, operation reports were re-audited on an equal number of patients. An operative note proforma was developed and third audit was carried out. The results of each audit were compared. Results: In the first audit, it was found that fourteen parameters were written with more than 90% accuracy. The first audit revealed seven poor areas in documentation: time of operation (0%), identification of emergency/elective procedure (0%), identification of any prosthesis or devices used (65.3%), details of closure technique (36.6%), name of anesthesiologist (0%), patient position (1.3%), and amount of bleeding (0%). In the second audit there was an incomplete, but significant improvement in these seven parameters (28%, 28.6%, 82%, 75.3%, 31.3%, 32%, and 34% respectively). Following introduction of the proforma; third audit cycle demonstrated a clear improvement in operation note documentation with at least 80% compliance in all parameters. Conclusion: This study revealed that the accuracy of the operating room documents can be improved through audits, education of surgeon and using proformas. The use of proforma provides much better results. ª 2019 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
* Corresponding author. Ege Universitesi Tıp Faku ¨ltesi Hastanesi, Genel Cerrahi, Bornova, Izmir, 35100, Turkey. Fax: þ90 232 339 88 38. E-mail address: [email protected] (O. Bozbiyik). https://doi.org/10.1016/j.asjsur.2019.10.002 1015-9584/ª 2019 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Please cite this article as: Bozbiyik O et al., Improving the quality of operation notes: Effect of using proforma, audit and education sessions, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.10.002
+
MODEL
2
O. Bozbiyik et al.
1. Introduction Clinical record keeping is an integral component in the delivery of quality healthcare.1 Both from a medical and legal point of view, the quality of operative notes are important. It should enhance communication between different healthcare professionals.2 Well-documented records can be useful for care of the patients, medical research and long-term follow-up.3 Neither in textbooks nor in literature there is not enough information about how to write a standard operation note. Royal College of Surgeons (RCS) Guidelines have identified eighteen criteria of operation note documentation for “Good Surgical Practice”.4 These criteria are: patient name, date of birth, hospital number, date of operation, time of operation, elective/emergency procedure, name of the operating surgeon, name of operating assistant, name of operation, the incision, operative findings/diagnosis, intra-operative complications, any extra procedure performed and the reason why it was performed, details of tissue removed, added or altered, identification of any prosthesis or devices used, details of closure technique, post-operative care instructions, and signature of surgeon. In this study, we hypothesized that the quality of operation notes could be improved by audit, educational sessions and using a proforma, including RCS Guideline criteria.
2. Methods We carried out a prospective audit on operation note documentation at Ege University Hospital, Department of Surgery over a four week period in April 2016. Notes were analyzed and reviewed for completeness. In the first audit, 150 operation notes were audited for compliance with eighteen criteria of the Royal College of Surgeons ‘Good Surgical Practice’ Guidelines. Seven additional criteria were also included. These additional criteria are:
name of anesthesiologist name of operating nurse type of anesthesia patient position side of operation (right/left) diagnosis after operation amount of bleeding
One hundred fifty operation notes were consecutively and randomly selected from upper gastrointestinal surgery (n Z 50), endocrine surgery (n Z 50) and emergency surgery (n Z 50). Equal number of notes was reviewed from each surgical subspecialty in each audit. Following the first audit, results were announced in an in-clinic training session and guidelines were discussed. An aide-memoire containing guideline parameters was placed in the operating theaters. After eight months on December 2016, one hundred fifty operation reports were re-audited on an equal number of patients from each surgical subspecility (upper gastrointestinal surgery (n Z 50), endocrine surgery (n Z 50) and emergency surgery (n Z 50)). After second audit cycle, a computerized operative note
proforma including the RCS Guideline criterias was developed and introduced into practice in January 2019. The audit was repeated over a four week period in June 2019. Again one hundred fifty operation notes were randomly selected from same surgical subspecialties (upper gastrointestinal surgery (n Z 50), endocrine surgery (n Z 50) and emergency surgery (n Z 50)). All of the operation notes were written by trainees (chief residents) or attending surgeons on electronic medical record system. It was not possible to fulfill all criteria in one operation. Terms were evaluated in the broadest sense as much as possible In the third audit, It was easy to evaluate because each criterion had a gap. In the first and second audits we evaluated the criteria in the broadest sense. If ‘midline’ is written for side of operation, we have accepted that as correct. While evaluating the ‘Any protesis and devices used’ criterion, in thyroid surgery, it was checked whether the energy device used or neuromonitoring device was written or not. Similarly, in the gastrointestinal system surgery, staplers used were expected to be written. Although each criterion is not suitable for all types of surgery, we have accepted that it is correctly written if it is not possible to fulfill those criteria.
2.1. Brief summary of procedures to improve the quality of the surgical report After the first audit, the results of the audit were presented to the surgeons and an education was given on the parameters that the surgical notes should contain. An aide memoire card was printed to remind surgeons about the Royal College of Surgeons guidelines, and hanged at operation room’s computer terminal. After the second audit, the results of first and second audit presented to surgeons and again an education was held. Beside this, operative note proforma including criterias was developed and proforma was installed on operating room computers and surgeons were provided to use. All statistical analysis was performed using SPSS (version 25.0; SPSS Inc, Chicago, IL) The results of each audit were compared and statistically analyzed using Cochran’s Q test for each standard. McNemar’s test is used to compare two audits (audit 1 vs audit 2 and audit 2 vs audit 3). A p value of <0.05 was considered statistically significant.
3. Results A total of 450 operation notes were reviewed, involving 150 operation notes in each audit cycle. Operations ranged from simple drainage of abscesses to complex laparoscopic cancer surgery. In the first audit, it was found that eighteen parameters were written with more than 90% accuracy. The first audit revealed seven poor areas in documentation of time of operation (n Z 0), emergency/elective procedure (n Z 0), identification of any prosthesis or devices used (n Z 98, 65%), details of closure technique (n Z 55, 37%), name of anesthesiologist (n Z 0), patient position (n Z 2, 1%), and amount of bleeding (n Z 0). In the second audit there was an incomplete, but significant improvement in these seven parameters (28%, 28.6%, 82%, 75.3%, 31.3%, 32%, and 34%
Please cite this article as: Bozbiyik O et al., Improving the quality of operation notes: Effect of using proforma, audit and education sessions, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.10.002
+
MODEL
Improving the quality of operation notes
3
respectively) (Fig. 1). Following introduction of the proforma; third audit cycle demonstrated a clear improvement in operation note documentation with at least 80% compliance in all parameters (Table 1).
4. Discussion Detailed and accurate writing of surgical note is important in quality based patient management. Nevertheless, this issue has not been adequately addressed in textbooks and literature. The RCS Guidelines, published in 2008, outlined eighteen criteria that should have been in a surgical operation note.4 Previous studies have assessed quality of operation notes according to RCS guidelines and described different methods to improve the quality of operation notes.2e7 In this study, the quality of operation notes increased with education, supervision and using proformas. It is known that use of electronic databases and proformas are important to increase the quality of operation notes.8,9 Despite the use of electronic medical record system in our hospital, our first audit revealed that four parameters of RCS guidelines and additional three parameters were insufficient. Similar to previous studies, this study demonstrated that documentation in operation notes was generally poor.6e10 Therefore, an education session was held and an aide-memoire containing guideline parameters was placed in the operating theaters. After waiting for a reasonable period for adaption, during the second audit we found out that these seven parameters moderately improved. Nevertheless, dissimilar to studies in the
100
93.3
94.6
91.3
91.3
88.6
90
82
83.3
80.6 75.3
80 65.3
70 60 50
36.6
40
34
32
31.3
28.6
28
30
First Audit (%) Second Audit (%) Third Audit (%)
20 10 0
0
0
1.3
0
0
Figure 1 Table 1
Significantly improving seven parameters.
literature, this improvement was not sufficient. The use of aide-memoire containing guideline parameters to increase the quality of surgical notes is known, but they were not sufficient in our study.9,11 It is not easy to recover a habit that has been settled for a long time. Some parameters, which are not recorded to operation note by the surgeon, are recorded to other forms by operating room nurse or anesthesiologist.10 For example, parameters such as antibiotic prophylaxis, amount of blood used, duration of surgery are documented by the anesthesiologist on intraoperative anesthesia charts. However, it would be a good practice to document them in the operation note for clarity and ease of access. In our medical report system some datas like date of operation, operating surgeon, operating assistant, operating nurse, type of anesthesia, name of operation have special boxes. We have noticed that datas which have boxes to be filled has been written at a higher rate. So we prepared an operative note proforma, including RCS criteria. In this study, after introducing an operative note proforma, third cycle audit resulted in a significant improvement in the quality of the reports. Using proforma is a cheap and easy method of improving the quality of medical records.5 In this paper, we put forward further evidence of using operation note proforma is more effective than education session and using aide-memoir in operation theaters. This is easy to understand, because it is much easier to fill gaps in proforma. We would strongly recommend that each surgical deparment regularly audits its practice and uses a simple proforma. It is considered necessary to use a clear and complete note to prevent unnecessary delays or errors in management during post-operative period.9,10 It is difficult to evaluate whether improvement of operation note quality actually leads to superior patient outcomes. This is a common limitation to studies aiming to improve operation note quality. Further studies are needed whether high quality surgical notes improve patient outcomes. One of the limitations of this study is lack of equal time between audits. At the beginning, this research was planned as a two-step study. But when the increase in the quality of the surgical report was not sufficient, a third step including operation note proforma was planned. Additional time is required to prepare proforma and introduce into practice. This study revealed that the accuracy of the operating room documents can be improved through audits,
Comparison of parameters showing improvement in compliance.
Time of operation Emergency/elective procedure Identification of any prosthesis& devices used Details of closure technique Name of anesthesiologist Patient position Amount of bleeding
First Audit (n:150)
Second Audit (n:150)
Third Audit (n:150)
p (*)
0 0 98
42 43 123
140 137 137
0.001 0.001 0.001
55 0 2 0
113 47 48 51
142 121 125 137
0.001 0.001 0.001 0.001
p(c) (1st &2nd)
p(c) (2nd &3rd)
0.001
<0.001 0.001 0.001
0.001 0.001
0.001 0.001 <0.001 <0.001
(*): Cochran Q test, (c): Mc Nemar Test.
Please cite this article as: Bozbiyik O et al., Improving the quality of operation notes: Effect of using proforma, audit and education sessions, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.10.002
+
MODEL
4
O. Bozbiyik et al.
education of surgeon and using proformas. The use of proforma provides much better results. In conclusion, effectiveness of a combination of education and operative note proforma was shown.
5.
Funding
6.
The study was not funded by any organization.
Declaration of Competing Interest The authors have no conflicts of interest to declare.
7.
8.
References 9. 1. Mathioudakis A, Rousalova I, Gagnat AA, Saad N, Hardavella G. How to keep good clinical records. Breathe. 2016;12:371e375. 2. Ma GW, Pooni A, Forbes SS, et al. Quality of inguinal hernia operative reports: room for improvement. Can J Surg. 2013;56: 393e397. 3. Ahearn N, Barbur S, Barksfield R, et al. Assessing the quality of operation notes: a review of 1092 operation notes in 9 UK hospitals. Patient Saf Surg. 2016;10:5. 4. Royal College of Surgeons. Good surgical practice section 1.3. www.rcseng.ac.uk/-/media/files/rcs/standards-and-
10.
11.
research/gsp/gsp-2014-web.pdf?laZen; 2014. Accessed March 1, 2019. Payne K, Jones K, Dickenson A. Improving the standard of operative notes within an oral and maxillofacial surgery department, using an operative note proforma. J Maxillofac Surg. 2011;10:203e208. Scherer R, Zhu Q, Langenberg P, Feldon S, Kelman S, Dickersin K. Comparison of information obtained by operative note abstraction with that recorded on a standardized data collection form. Surgery. 2003;133:324e330. Din R, Jena D, Muddu BN. The use of an aide-memoire to improve the quality of operation notes in an orthopaedic unit. Ann R Coll Surg Engl. 2001;83:319e320. Laflamme MR, Dexter PR, Graham MF, Hui SL, McDonald CJ. Efficiency, comprehensiveness and cost-effectiveness when comparing dictation and electronic templates for operative reports. AMIA Annu. Symp. Proc. 2005;2005:425e429. Singh R, Chauhan R, Anwar S. Improving the quality of general surgical operation notes in accordance with the Royal College of Surgeons guidelines: a prospective completed audit loop study. J Eval Clin Pract. 2012;18:578e580. Parwaiz H, Perera R, Creamer J, Macdonald H, Hunter I. Improving documentation in surgical operation notes. Br J Hosp Med. 2017;78:104e107. Shayah A1, Agada FO, Gunasekaran S, Jassar P, England RJ. The quality of operative note taking: an audit using the Royal College of Surgeons Guidelines as the gold standard. Int J Clin Pract. 2007;61:677e679.
Please cite this article as: Bozbiyik O et al., Improving the quality of operation notes: Effect of using proforma, audit and education sessions, Asian Journal of Surgery, https://doi.org/10.1016/j.asjsur.2019.10.002