Start Submission Become a Reviewer

Reading: An analysis of operative notes in major surgeries at a teaching hospital

Download

A- A+
Alt. Display

Brief Reports

An analysis of operative notes in major surgeries at a teaching hospital

Authors:

K. Sivasuganthan ,

Teaching hospital Jaffna, LK
About K.
University surgical unit
X close

S.T Sarma,

Teaching hospital Jaffna, LK
About S.T
University surgical unit
X close

M Suman

Teaching hospital Jaffna, LK
About M
University surgical unit
X close

Abstract

Introduction
Operative (OP) note is an important document, which should be recorded immediately after surgery. It should be accurate and in detail, for management of the patient and for legal purposes. In our contest, it's written by surgical trainees and supervised by senior surgeons, which is an important part of
surgical training.


Materials and methods
We have analysed 215 major surgical OP notes including elective and emergency surgeries in general surgical units, Teaching Hospital Jaffna, from 1st of July 2016 to 31st of December 2016.


Results
All surgeries were performed under general anaesthesia and 83.3 % (n=179) performed by consultants. 90% of OP notes didn't contain time of the surgery, but date of the surgery was
mentioned in 82.1% (n=195). Details of surgical team were mentioned in 98.2%, but details of anaesthetic team mentioned in 8.3 %( n=18). Operative diagnosis was missed in 48.8% (n=110) of OP notes. Details of closure technique was not mentioned in 15.5% and none of the notes contained
detail of blood loss. Monitoring vital parameters, fluid management and pain management were mentioned 78%, 50%, and 89.9% respectively. Only 6.5% of OP notes were signed by the person who has written.


Conclusion and recommendation
Operative notes were incomplete in most cases. Several areas were identified for further improvement. Pre-designed surgery specific post-operative forms can be used in operating theatres to improve documentation of op notes.

How to Cite: Sivasuganthan, K., Sarma, S.T. & Suman, M., (2018). An analysis of operative notes in major surgeries at a teaching hospital. Sri Lanka Journal of Surgery. 36(2), pp.29–31. DOI: http://doi.org/10.4038/sljs.v36i2.8513
Published on 31 Aug 2018.
Peer Reviewed

Downloads

  • PDF (EN)

    comments powered by Disqus