4
views
0
recommends
+1 Recommend
0 collections
    0
    shares
      • Record: found
      • Abstract: found
      • Article: not found

      Improving operation notes to meet British Orthopaedic Association guidelines.

      Annals of The Royal College of Surgeons of England
      Arthroplasty, Replacement, Knee, Education, Medical, Continuing, General Surgery, education, Humans, Medical Audit, Medical Records, standards, Practice Guidelines as Topic, Professional Practice, Prospective Studies

      Read this article at

      ScienceOpenPublisherPMC
      Bookmark
          There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

          Abstract

          Operation notes are an important part of medical records for clinical, academic and medicolegal reasons. This study audited the quality of operative note keeping for total knee replacements against the standards set by the British Orthopaedic Association (BOA). A prospective review of all patients undergoing total knee replacement at a district general hospital over 8 months. Data recorded were compared with those required by the BOA good-practice guidelines. Change in practice was implemented and the audit cycle completed. Data were statistically analysed. A total of 129 operation notes were reviewed. There was a significant improvement in the mean number of data points recorded from 9.6 to 13.1. The least well recorded data were diagnosis, description of findings, alignment and postoperative flexion range. All had a significant improvement except description of findings. The operating surgeon writing the note improved from 56% to 67%. Detailed postoperative instructions also improved in quality. Surgeon education and the use of a checklist produce better quality total knee replacement operation notes in line with BOA guidelines. Further improvements may be made by making the data points part of the operation note itself.

          Related collections

          Author and article information

          Comments

          Comment on this article