Amit Kumar, Neel Kamal Gola, Devendra Kumar Shiwach
2016 Journal of Evolution of Medical and Dental Sciences  
AIM The operative note describes the indication and steps of surgery performed forms the base of surgical care. It is the repository of perioperative events, which are queried in case of adverse events for research activities and sometimes in medicolegal cases. In order to be useful, it must be objective, complete, and reflect the operation it is supposed to describe. This study evaluates the quality of operative notes in our setup. METHODS One hundred two charts of patients undergoing
more » ... pic cholecystectomy in three hospitals during the period August to November 2015 were evaluated against Good Surgical Practice recommended by Royal College of Surgeons of England and with a standard format for laparoscopic cholecystectomy, which emphasised intraoperative details with the intention of preventing operative mishaps. RESULT Of the 102 patients' record, 32% were deficient regarding multiple parameters. Only 58 (56.85%) of the records mentioned critical view of safety. Eighty two (80.3%) of patient's notes mentioned the insertion of laparoscopic ports under vision and in 90 (88.2%) cases the description of dissection and clipping of cystic duct or artery was present. The duration of operation was mentioned in 67 charts and presence or absence of drain was noted in 81 (79%) operative records. Sixty four (62%) charts lacked any mention of DVT prophylaxis and 43.3% lacked notes regarding estimated blood loss. Involvement of residents in the operation were more likely to be detailed in their operation note. Video record of thirty three operations was present. CONCLUSION All the charts reviewed had mention of names of operating surgeons, anaesthesia, diagnosis, and postoperative instructions. The missing information like details of operation like critical view of safety, port removal and closure, a procedure specific form, or electronic charting with prompts can improve the quality of notes.
doi:10.14260/jemds/2016/995 fatcat:aklikrq7xngjlnezyj67escmfu