An Audit on Operative Note at National Academy of Medical Sciences (NAMS)

Maharjan R**, Maharjan R*,

Abstract


INTRODUCTION: Operation notes are an important part of medical records for clinical, academic research
and medico-legal reasons. Accurate medical record keeping is one of the primary skills required for
good clinical practice. To observe the completeness and proper documentation of the operative notes in
NAMS with respect to guidelines of RCS (Royal College of Surgeons) and to see the implementation of the
recommendations made by this study by doing rolling audit in future.

METHOD: Twenty files with operative notes were selected randomly from included surgical departments
and analyzed for the completeness according to the RCS guidelines. It was a retrospective study conducted in
National Academy of Medical Sciences, Bir Hospital from the date of approval from IRB, NAMS.

RESULT: Operation notes were not satisfactory in all the departments. All the operative notes were hand
written. Complication during surgery, any extra procedure performed, identification of any prosthesis used
including the serial numbers, Deep Vein Thrombosis (DVT) prophylaxis and details of postoperative care
instructions were not mentioned in all the departments.

CONCLUSION: All the departments must be aware of the proper record keeping in their respective
department. All surgeons will be made aware of the results of the first audit cycle and a second audit cycle
will be then carried out prospectively to evaluate the improvement in operative notes in future.

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