|Year : 2013 | Volume
| Issue : 1 | Page : 8-12
Effectiveness of teaching operation notes to surgical residents
Adel Johari, Nisar Haider Zaidi, Rakan F Bokhari, Abdulmalik Altaf
Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
|Date of Web Publication||13-Sep-2013|
Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah 21589
Source of Support: None, Conflict of Interest: None
Objective: The effectiveness of teaching operative notes in surgical resident training program at King Abdulaziz University Hospital, Jeddah was studied. Materials and Methods: This was a prospective study done at Department of Surgery, King Abdulaziz University Hospital to evaluate the effect of teaching the surgical residents how to write operative notes. Twenty-one residents were asked to write operative notes of appendicectomy. Their operative notes were evaluated for medical record number (MRN), date and time of the operation, preoperative and postoperative diagnosis, names of surgeon, assistant, and anesthetist, name of the operation, incision, findings, closure, hemostasis, estimated blood loss, whether histopathology specimen was sent to the pathology department or not, postoperative orders, whether the patient went to the recovery room in a satisfactory condition or not, and signature of the operating surgeon. Two months of effective teaching of operative notes was given to them. They were again asked to write operative notes of appendicectomy. Notes were collected and studied and comparison was made with previous notes. Legibility of the operative notes was also studied. Results: In our study, we found that there was improvement of 29-39.9% in recording MRN and the date of operation by our residents after they were taught the art of writing operation notes. There was marginal improvement (4.7%) in stating whether it was elective or emergency operation. Documentation of surgeon's name, assistant's name, and anesthetist's name improved to 12.4-32.8%. Writing the name of the procedure and pre- and postoperative diagnosis improved to 31%. Details of the procedure such as position of patient and incision improved marginally to 5.9%. Mentioning the findings and description of the procedure showed no improvement, as it was 100% before teaching. Documenting hemostasis, estimated blood loss, and transfer to recovery room improved to 58.4%; however, there was no improvement in writing post-op orders and histopathology sent to the pathology department.Improvement of signature was only 9%. Conclusion: Effective teaching of how to write operative notes helps in the training of surgical residents.
Keywords: Guidelines, operative notes, quality, teaching
|How to cite this article:|
Johari A, Zaidi NH, Bokhari RF, Altaf A. Effectiveness of teaching operation notes to surgical residents. Saudi Surg J 2013;1:8-12
| Introduction|| |
Good surgical practice requires excellent patient care, good communication skills, and clear and detailed medical records. Surgical records need to be clear, and they must contain sufficient details to enable continuity of care by other health care providers. Operative procedures are incomplete if not reflected by detailed operative notes. Operative reports dictated by surgical residents are often incomplete or inaccurate, which likely leads to reduced or delayed reimbursement.  According to the surgical practice guidelines published by the Royal College of Surgeons of England, operative notes should include date and time, elective/emergency procedure, the names of the operating surgeon and assistant, the operative procedure carried out, the incision, the operative diagnosis, operative findings, any problems/complications, any extra procedure performed and the reason why it was performed, details of tissue removed, added, or altered, identification of any prosthesis used including the serial numbers of prostheses and other implanted materials, details of the closure technique, postoperative care instructions, and a signature. 
Little emphasis has been given to the process of teaching how to write operative notes or to the fact that this should be part of core surgical-skills teaching for future trainees.  The National Confidential Enquiry into Perioperative Deaths reported that the quality of operative notes was substandard and there is a need for improvement.  Litigation has risen in recent years due to shortcuts taken in writing operative notes in the operating room.  Operative notes are not only essential for the appropriate medical care of patients, but also form an essential part of research projects, audits, billing, and medicolegal purposes. , In our study, we looked at the effect of teaching a standardized model of operative notes to our surgical residents.
| Materials and Methods|| |
A prospective study was performed in the Department of Surgery, King Abdulaziz University Hospital, Jeddah to evaluate the effect of teaching surgical residents a standard model of writing operative notes. Approval of the King Abdulaziz University ethics committee was received in compliance with the Helsinki Declaration, prior to beginning the research. A random sample of 21 junior-year surgical residents (PGY-I, PGY-II) was selected for the study. The standard model of writing operative notes was taught to the residents. The session was conducted by the program director of general surgery training using a PowerPoint ® slideshow presentation focusing on the appropriate way of writing a legible operative note. During the session, 22 variables that are important to be included in any operative note were emphasized. The residents were asked to write operative notes of an appendectomy before and 2 months after the teaching session. On both occasions, the operative notes were examined with regard to the 22 variables, including the patient's medical record number (MRN), date and time of the operation, pre- and postoperative diagnosis, names of the surgeon, assistant, and anesthetist, name of the operation, incision, findings, closure, hemostasis, estimated blood loss, histopathology specimen, patient's condition on transfer to the recovery room, and signature. Using standard statistical tests, a comparison was made between residents' notes that were written before and after the teaching session, and the results were analyzed.
| Results|| |
We found that prior to teaching, 47% of the residents mentioned MRN [Table 1] and 41% wrote the date, but none mentioned the time or whether the procedure was elective or emergency. The names of the surgeon, assistant surgeon, and anesthetist were written by 58.8%, 52.9%, and 35.2%, respectively. Preoperative diagnosis, postoperative diagnosis, name of the procedure, and anesthesia were mentioned by 64%, 58.8%, 58.8%, and 94.1%, respectively. The position of the patient, incision, and description of the procedure were written by 82.3%, 94.1%, and 100%, respectively. None of the residents mentioned any problems encountered. Histopathology sent, hemostasis achieved, and blood loss were mentioned by 29.4%, 52.9%, and 17.6%, respectively. None mentioned postoperative orders. Closure details, transfer to recovery room, and signature were recorded by 100%, 52.9%, and 52.9%, respectively.
After the residents were taught, 76% of them mentioned MRN [Table 2] and 80.9% wrote the date, but only 28.5% mentioned the time and only 4.7% mentioned whether the procedures was elective or emergency. The names of the surgeon, assistant surgeon, and anesthetist were written by 85.7%, 85.7%, and 47.6%, respectively. Preoperative diagnosis, postoperative diagnosis, name of the procedure, and anesthesia were mentioned by 90.4%, 90.4%, 80.9%, and 85.7%, respectively. The position of the patient, incision, and description of the procedure were written by 85.7%, 100%, and 100%, respectively. None of residents mentioned any problems encountered. Histopathology sent, hemostasis achieved, and blood loss were mentioned by 28.5%, 85.7%, and 76%, respectively. Closure details, transfer to recovery room, and signature were recorded by 100%, 80.9%, and 61.9%, respectively.
The differences between before and after teaching were statistically significant [Table 3], [Figure 1].
| Discussion|| |
Modern surgical practice emphasizes providing the best care to patients and ensuring their safety. Documentation of events is essential for the patient's care and the continuity of care by other surgeons and health care providers. Ideally, the operative note would consist of a general section and a procedure-specific section to allow a step-by-step operative description.  The Dutch guidelines recommend that operative notes are "dictated, made available, and added to the medical record as soon as possible."  Operative notes that are written immediately after completion of a surgical procedure contain more detailed information about the procedure. The Joint Commission defines immediately as "occurring upon completion of surgery, before the patient is transferred to the next level of care."  At present, only 10-18% of institutions globally offer operative note-writing as part of their residency program curriculum and most senior surgeons have never received such training. ,,
In our study, we found an improvement of 29-39.9% in recording MRN and date of the operation by our residents after they were taught the art of writing operative notes. There was marginal improvement of 4.7% in stating whether the procedure was an elective or emergency operation. Documentation of the surgeon's name, assistant's name, and anesthetist's name improved between 12.4% and 32.8%. Mentioning the name of the procedure and pre- and postoperative diagnosis improved by 31%. Writing the details of the procedure such as the position of patient and the incision improved marginally (5.9%). Stating the operative findings and description of the procedure had no improvement, as it was 100% before teaching. Mentioning hemostasis, estimated blood loss, and transfer to the recovery room improved by 58.4%; however, there was no improvement in stating the histopathology specimen that was sent. Improvement of signatures was only 9%.
Our study shows that there is significant improvement in operative notes after teaching. Al Hussainy et al. reported the impact of introducing proforma documentation of operative notes and found significant improvement.  Barrit et al. also reported improvement in operative notes after introducing detailed, computerized proforma operative notes.  Lawrence et al. reported that most (80%) residents felt that their program did not use any formal methods to help improve their dictation of operative notes, and 70% of them even requested further training in dictation.  Several audit studies have shown considerable improvement in the quality of operative notes after the introduction of memory aids, consisting of either proforma with mandatory headings or simple reminder lists, in order to prompt the inclusion of certain information. ,, Based on our results, we advise introducing specific teaching sessions for writing operative notes to surgical residency training programs.
| Conclusion|| |
Effective teaching of how to write operative notes helps in the training of surgical residents. Improving these documents is necessary to provide optimum patient care, and it is needed to comply with the legal requirements for medical record keeping. We recommend teaching the art of writing operative notes as part of the curriculum for surgical residency training programs.
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[Table 1], [Table 2], [Table 3]
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