Tolesa Chimdesa¹, Wondwossen Amtataw¹* and Trhas Tadesse²

¹Department of Surgery, Yekatit 12 Hospital Medical College, Addis Ababa, Ethiopia
²Department of Public Health, Yekatit 12 Hospital Medical College, Addis Ababa, Ethiopia

*Corresponding Author: Wondwossen Amtataw, Department of Surgery, Yekatit 12 Hospital Medical College, Addis Ababa, Ethiopia.

Received: March 25, 2024; Published: April 19, 2024

Abstract

Background: Surgeons must maintain accurate, legible, and up-to-date records of patient information for optimal care and safety. However when use of computerized operation notes, posing initial challenges for surgeons until they adapt and the system matures. Addressing these challenges is crucial for improving caregiver practices and overall patient safety.

Objectives: To assess the quality of computerized operation in the department of general surgery.

Methods: A cross-sectional study design was utilized, and data entry and analysis were conducted using SPSS version 25. Chi-square tests were applied to selected parameters assumed to significantly impact patient safety.

Result: The entire computer auto generated elements such as time and date was 100% typed. Whereas some important element of the standard like the name of the anesthetist, scrub and circulating nurse, whether prophylactic antibiotics were given or not and the need for deep vein thrombosis prophylaxis were not typed at all. Overall the quality of operation note is poor and factors contributing to the poor adherence to the standard set by Royal College of surgeons’ guideline are the knowledge gap, the poor design of the system compared to the system.

Conclusion: There's a notable gap in the technical aspects of operations regarding standard elements. Urgent refinement of the system and teaching are needed to ensure better patient care continuity and meet operation note writing standards.

Keywords: Operation Notes; Medical Records; RSCE; Poor Quality

References

1. Younis MU. “Importance Of Efficient Operation Note Writing: Review of Guidance”. Journal of Ayub Medical College Abbottabad-Pakistan1 (2021).
2. Elbagir Ali A E and E Abdulkhalig Hussain. “Facts about compliance of surgeons" an audit study of the quality of operation notes in the department of general surgery, King Faisal Hospital, Makkah, Saudi Arabia". (2009).
3. Johari A., et al. “Effectiveness of teaching operation notes to surgical residents”. Saudi Surgical Journal1 (2013): 8-12.
4. Audit S., et al. “Assessing the quality of operation notes: a review of 1092 operation notes in 9 UK hospitals”. Patient Safety in Surgery (2016): 10.
5. Blackburn J. “Assessing the quality of operation notes: a review of 1092 operation notes in 9 UK hospitals”. Patient Safety in Surgery (2016): 10.
6. Rogers AD. “The quality of operative notes at a general surgery unit”. South African Medical Journal9 (2008): 726-728.
7. Kawu A., et al. “Operative notes in orthopaedic surgical care in Nigeria”. International Journal of Biological and Medical Research 3 (2011): 668-670.
8. Eryigit Ö., et al. “A systematic review on the synoptic operative report versus the narrative operative report in surgery”. World Journal of Surgery 43 (2019): 2175-2185.
9. Hamza AA., et al. “Evaluating the operative notes of patients undergoing surgery at Omdurman Teaching Hospital, Sudan”. Scholars Journal of Applied Medical Sciences 6 (2013): 668-672.
10. Wauben LS., et al. “Evaluation of operative notes concerning laparoscopic cholecystectomy: are standards being met?” World Journal of Surgery 34 (2010): 903-909.
11. Javid, M., et al. “A prospective closed loop audit on the quality of the operative notes in a general surgical unit in a quaternary care centre”. International Surgery Journal2 (2020): 382-384.
12. Bhatti DS., et al. “Royal College of Surgeons guideline adherence on improvement of operative notes: a six-month closed loop audit”. Cureus5 (2020).
13. Day A., et al. “The Royal College of Ophthalmologists’ National Ophthalmology Database study of cataract surgery: report 1, visual outcomes and complications”. Eye4 (2015): 552-560.
14. Rogers BA and J Pleat. “Is there adequate information on operation notes? The application of the Royal College of Surgeons of England guidelines”. Journal of Perioperative Practice9 (2010): 339-342.
15. Singh R., et al. “Improving the quality of general surgical operation notes in accordance with the Royal College of Surgeons guidelines: a prospective completed audit loop study”. Journal of Evaluation in Clinical Practice3 (2012): 578-580.
16. Hoggett L., et al. “How to write an operation note”. BMJ (2017): 356.
17. Khalid A., et al. “Audit of operative notes against Royal College of Surgeons guidelines in a tertiary health care surgical unit in Lahore”. Cureus 9 (2022).
18. Nzenza TC., et al. “Quality of handwritten surgical operative notes from surgical trainees: a noteworthy issue”. ANZ Journal of Surgery3 (2019): 176-179.
19. Solomon M., et al. “Clinical audit of operation notes at the Department of Surgery, Addis Ababa University”. East and Central African Journal of Surgery1 (2020).
20. Babalola R., et al. “An audit of the quality of surgical operation notes in a Nigerian teaching hospital”. East and Central African Journal of Surgery2 (2016): 76-80.
21. Abbas S., et al. “A thorough note: does a procedure-specific operation note proforma for laparoscopic appendicectomy improve compliance with the Royal College of Surgeons of England Guidelines?” International Journal of Surgery Open 2 (2013): 1-5.

Citation

Citation: Wondwossen Amtataw., et al. “Assessment of the Quality of Computerized Operation Notes at Yekatit 12 Hospital Medical College".Acta Scientific Clinical Case Reports 5.5 (2024): 21-25.

Copyright

Copyright: © 2024 Wondwossen Amtataw., et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.