Quality of Operation Notes in Niger-Delta University Teaching Hospital, Southern Nigeria

Abstract

Background: Operation notes are necessarily a vital part of good note keeping in clinical surgery as they are useful tools in patients management. They are also useful in research, audit of procedures and a sine qua non should medico-legal dispute arise. Ideally operation notes should be written by operating surgeon. This article assesses the quality of operation notes in a young teaching hospital. Method: A total of 99 operation notes were randomly selected from a list of surgical operations between July 2008 and June 2010 of a young teaching Hospital. The operation notes were assessed for expected parameters of a standard operative note against the background of hospital templates and published protocol derived from Good surgical practice by the Royal college of surgeons, Edinburgh, 2008. Available components in the written notes were tabulated. Result: Results showed that all the operative notes were incomplete for all parameters. Deficiencies ranged from 1% for written operative procedure to as high as 96% for tolerance. Other deficiencies were at rates of ;5,7,10, 29, 45, 56 and 58 percentages for name of patient, name of surgeon, admission number, indications, blood loss and positioning respectively. Conclusion. Regular audit of operation notes should be carried out and medical personnel should be properly trained concerning writing of operation notes in a legible, comprehensible and briefly way with the goal of achieving best medical practice.