AUDIT OF OPERATIVE NOTES AGAINST ROYAL COLLEGE OF SURGEONS GUIDELINES AT GENERAL HOSPITAL IN KANO, NIGERIA alhassann428@gmail.com

 

AUDIT OF OPERATIVE NOTES AGAINST ROYAL COLLEGE OF SURGEONS GUIDELINES AT GENERAL HOSPITAL IN KANO, NIGERIA

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Nigeria

Poster Exhibition only

Operative note is an essential document that provides information on all the happening during and after surgical operation. It serves significant roles not only in patient care and outcome but also for medico-legal purpose and as well as a measure of good medical practice

An audit was conducted using 50 operation notes from Orthopedic Surgery Unit of Sir Muhammad Sunusi Specialist Hospital (SMSSH) and compare with the checklists from the Royal college of Surgeon as gold standard. Each parameter was assessed as either present or absent and entered into an excel sheet. Data analysis was done using SPSS version 27.0 and results were presented in a frequency table.

Patient identification, date of procedure, anesthesia given, name of surgeon, and anesthetist, and details of post-operative instructions were documented in 100% (50) of the operation notes making them the most documented parameter followed by name of assistant and signature which is recorded in 98% (49) of the document. The least documented parameters include; type of incision, time of procedure, and details of closure technique which is documented in 4%, 2%, and 2% respectively. DVT and antibiotic prophylaxis, anticipated blood loss, problem/complications, and type of surgery was not documented in any of the operation notes.

A good, legible, and inclusiveness of all the components of operation notes made by surgeon is quite essential not only for the benefit of the patients being operated but also keep the surgeon and the entire surgical team in state of competencies during medico-legal situations.