Assessing the Quality of Operative Notes in the Orthopedic Surgery Department at Gezira Traumatology Center, Sudan, in Accordance With the Royal College of Surgeons Guidelines.

BACKGROUND

High-quality operative notes are crucial for patient safety, continuity of care, and medico-legal protection. Despite established Royal College of Surgeons (RCS) guidelines, audits globally reveal persistent deficiencies in surgical documentation. This study assessed the quality of operative notes in the Orthopedic Surgery Department at Gezira Traumatology Center, Wad Madani Teaching Hospital, Sudan, and evaluated the impact of targeted interventions.

METHODS

A clinical audit was conducted in two cycles (in July 2023 and then three months post-intervention). In the first cycle, 23 randomly selected orthopedic operative notes were retrospectively audited against 14 RCS documentation parameters. Root cause analysis identified key deficiencies. A multi-faceted intervention was implemented, including staff education, a standardized RCS-aligned template, visual reminders, and a feedback mechanism. The second cycle re-audited 23 notes using the same criteria. Data were analyzed using descriptive statistics.

RESULTS

Pre-intervention, compliance was high for procedure (95.7%), diagnosis (95.7%), and signature (100%), but critically low for theatre anesthetist's name (4.3%), anticipated blood loss. (13%), and antibiotic prophylaxis (8.7%). Post-intervention, significant improvements were noted in documenting the anesthetist's name (82.6%), anticipated blood loss (82.6%), complications (91.3%), and antibiotic prophylaxis (69.6%). However, unexpected declines were observed in documenting prosthesis identification (from 87% to 26.1%) and tissue details (from 87% to 65.2%). High-compliance areas generally remained stable.

CONCLUSION

Implementing a standardized operative note template based on RCS guidelines, combined with education and feedback, significantly improved the completeness of critical documentation elements in orthopedic operative notes. The decline in documenting prosthesis and tissue details highlights the need for focused reinforcement and ongoing monitoring to achieve consistent, comprehensive compliance. Standardized templates are highly effective tools for enhancing surgical documentation quality.