METHODS: We audited 100 consecutive Oral and Maxillofacial Surgery operations performed within general theatres. As an intervention we designed and piloted a paper based Operative Note Proforma and re-audit was undertaken.
RESULTS: Initial audit showed results lacking in certain areas. At re-audit all audit criteria showed improvement. The mean percentage of data point inclusion rose from 76.1 to 98.3% (0.001 < P-value < 0.005).
CONCLUSIONS: Previous papers have discussed various methods of improving operative note standards. We present statistical evidence for the use of an Operative Note Proforma to improve operative note standards within Oral and Maxillofacial Surgery.