This was an audit and quality improvement project carried out at the Queen Elizabeth Hospital Birmingham in 2015 and was runner up in the Sage Surgical Prize 2015. The project analyse a large number of operation notes and then proposed how these notes could be improved to make caring for patients on the wards after surgery a bit easier for junior doctors and hence to improve patient care by making sure that all patients received exactly the post-operative care they required.

1. A “Skeletal” Op Note
Project Lead - Gp Capt I Sargeant
Senior Registrar - Mr S Evans
Surg. Lt. M Clarke
Fg Off E Farrar
Lt. J Matthews
Lt. L Rickard
Surg. Lt A Sales
Dr K Tadrak
CARMS No: 12417

2. Introduction
• Royal College of Surgeons – Good
Surgical Practice 2008
• British Orthopaedic Association
• Medico-Legal: only evidence of
procedure/ responsibility
• Peri-Operative communication

3. Why choose this topic?
• Nationally, operation notes = poorly completed
• Anecdotally:
– Op notes guide post op care (MDT)
– Often variable detail
– Sometimes confusing
– Specific information sometimes omitted
– Learn about procedures
– Quality improvement potential
Ghosk AK. An audit of orthopaedic operation notes: what are we missing?. Clinical Audit: 2010; 2 37-40

4. Method
• Hospital Informatics
• 1st November 2015 – 31st December 2015
• RCS “Good Surgical Practice” 2008
• Departmental Post-Op Guidance List

6. Results - Demographics
339 notes were analysed
306 individuals (149 female, 190 male)
Mean age was 51.4
94 individual primary operation codes

7. Results

8. Results
Post-Op
Instruction
Inclusion Score
Number
Documented
(n = 339)
%
0-3 75 22
4-6 210 62
7-9 54 16
10 0 0
New Post-Op Instruction
Criteria
Number
Documented
(n = 339)
%
[Common]
Antibiotics 181 53
VTE 112 33
Wound care/ Dressings 117 34
Post-Op Investigations 135 40
Discharge Instructions/
Expected LoS
120 35
Follow Up Plans 198 58
Removal of Sutures 97 29
[T/O specific]
Limb support
(PoP, Sling, Splint, Boot etc)
116 34
Range of Motion 71 21
Weight Bearing Status 220 65

9. Discussion
1. E-op note = still a wide variation
2. Clinically relevant fields = not completed
3. Time spent clarifying details and instructions
4. PICS (CDAG) + Consultants = Reformatting Op Notes
5. Op codes = HES coding + Re-imbursement
6. Op Code = ?Op Finding = ?Op Diagnosis

11. System re-designs

12. Recommendations
ESSENTIAL
1) Mandatory signature field
2) Mandatory “Anaesthetist” field
3) Mandatory operative diagnosis
4) Mandatory supervising surgeon
DESIRABLE
1) Standardised Post-op Instructions
2) Implant/ Prosthesis identification
3) NCEPOD/elective/ emergency
4) Operation coding

13. References
1. The Royal College of Surgeons of England. Guidelines for Clinicians on Medical Records and
Notes. London: RCSE, 1994
2. British Orthopaedic Association and British Association for Surgery of the Knee. Knee
replacement: A Guide to Good Practice. London: BOA, 1999
3. Al Hussainy H, Ali F, Jones S et al. Improving the standard of operation notes in orthopaedic
and trauma surgery: the value of a proforma. Injury. 2004; 35:1102-1106
4. Morgan D, Fisher N, Ahmad A & Alam F. Improving operation notes to meet British
Orthopaedic Association guidelines. Ann R Coll Surg Engl 2009 91; 217-219
5. Ghosk AK. An audit of orthopaedic operation notes: what are we missing?. Clinical Audit:
2010; 2 37-40