OBJECTIVE: Proper and adequate documentation in operation notes is a basic tool of clinical practice with medical and legal implications. An audit was done to ascertain if oral and maxillofacial surgery operative notes in an Indian public sector hospital adhered to the guidelines published by the Royal College of Surgeons England.
METHODS: Fifty randomly selected operative notes were evaluated against the guidelines by RCS England with regards to the essential generic components of an operation note. Additional criteria relevant to oral and Maxillofacial Surgery were also evaluated. Changes were introduced in the form of Oral and Maxillofacial Surgery specific consent forms, diagram sheets and a computerized operation note proforma containing all essential and additional criteria along with prefilled template of operative findings. Re-audit of 50 randomly selected operation notes was performed after a 6 month period.
RESULTS: In the 1st audit cycle, excellent documentation ranging from 94 to 100 % was seen in 9 essential criteria. Unsatisfactory documentation was observed in criteria like assistant name, date of surgery. Most consent forms contained abbreviations and some did not provide all details. Additional criteria specific to Oral and Maxillofacial Surgery scored poorly. In the 2nd Audit for loop completion, excellent documentation was seen in almost all essential and additional criteria. Mean percentage of data point inclusion improved from 84.6 to 98.4 % (0.001< P value <0.005). The use of abbreviations was seen in only 6 notes.
CONCLUSIONS: Regular audits are now considered a mandatory quality improvement process that seeks to improve patient care and outcomes. To the best of our knowledge, this is the first completed audit on operation notes documentation in Oral and Maxillofacial Surgery from India. The introduction of a computerized operation note proforma showed excellent improvement in operation note documentation. Surgeons can follow the RCS guidelines to ensure standardization of operation notes.