Audit of Orthopaedic Surgical Documentation
Joint Authors
Coughlan, Fionn
Ní Fhoghlu, Cliodhna
Moriarity, Andrew
Hogan, Niall
Ellanti, Prasad
Source
Issue
Vol. 2015, Issue 2015 (31 Dec. 2015), pp.1-4, 4 p.
Publisher
Hindawi Publishing Corporation
Publication Date
2015-08-19
Country of Publication
Egypt
No. of Pages
4
Main Subjects
Abstract EN
Introduction.
The Royal College of Surgeons in England published guidelines in 2008 outlining the information that should be documented at each surgery.
St.
James’s Hospital uses a standard operation sheet for all surgical procedures and these were examined to assess documentation standards.
Objectives.
To retrospectively audit the hand written orthopaedic operative notes according to established guidelines.
Methods.
A total of 63 operation notes over seven months were audited in terms of date and time of surgery, surgeon, procedure, elective or emergency indication, operative diagnosis, incision details, signature, closure details, tourniquet time, postop instructions, complications, prosthesis, and serial numbers.
Results.
A consultant performed 71.4% of procedures; however, 85.7% of the operative notes were written by the registrar.
The date and time of surgery, name of surgeon, procedure name, and signature were documented in all cases.
The operative diagnosis and postoperative instructions were frequently not documented in the designated location.
Incision details were included in 81.7% and prosthesis details in only 30% while the tourniquet time was not documented in any.
Conclusion.
Completion and documentation of operative procedures were excellent in some areas; improvement is needed in documenting tourniquet time, prosthesis and incision details, and the location of operative diagnosis and postoperative instructions.
American Psychological Association (APA)
Coughlan, Fionn& Ellanti, Prasad& Ní Fhoghlu, Cliodhna& Moriarity, Andrew& Hogan, Niall. 2015. Audit of Orthopaedic Surgical Documentation. Surgery Research and Practice،Vol. 2015, no. 2015, pp.1-4.
https://search.emarefa.net/detail/BIM-1076610
Modern Language Association (MLA)
Coughlan, Fionn…[et al.]. Audit of Orthopaedic Surgical Documentation. Surgery Research and Practice No. 2015 (2015), pp.1-4.
https://search.emarefa.net/detail/BIM-1076610
American Medical Association (AMA)
Coughlan, Fionn& Ellanti, Prasad& Ní Fhoghlu, Cliodhna& Moriarity, Andrew& Hogan, Niall. Audit of Orthopaedic Surgical Documentation. Surgery Research and Practice. 2015. Vol. 2015, no. 2015, pp.1-4.
https://search.emarefa.net/detail/BIM-1076610
Data Type
Journal Articles
Language
English
Notes
Includes bibliographical references
Record ID
BIM-1076610