Lakshmi Malvika Atluri
Royal College of Surgeons of Edinburgh, United Kingdom
Scientific Tracks Abstracts: Surgery Current Research
Statement of the problem: Operative notes are very important in all surgical specialties. They are very crucial in depicting the overall functioning of the department along with being used in research and audit purposes. Recently, there has been a lot of paucity in writing an efficient notes with complete details.This trend has increased over the last two decades and is unfortunately growing at an alarming rate. To improve the quality of surgical notes, the Royal College of Surgeons (RCS) established formal guidelines in 2014. These guidelines are short, focused and easily adaptable for any surgical specialty. They are the standard for operative notes and is the cornerstone of good medical practice and their implementation has been shown to dramatically increase the overall effectiveness of operative notes. Unfortunately, these notes are often overlooked and not given the necessary attention, time or skill. Methodology: Project sampling and data collection: Following an Ethical committee clearance and permissions from the Head of the department of General Surgery Dr.PSIMS&RF ,operative notes of all the surgeries held in March 2020,February 2020 along with January 2021 was collected from Medical Records Department. The operative notes of all the surgeries held in MAY,JUNE and JULY 2021 was collected from medical records department for a 2nd audit. Reaudit: The operative notes of all the surgeries held in MAY, JUNE and JULY 2021 was collected from medical records department. The operative notes of all surgeries held in September and October 2021 were collected. Prospective: Evaluation of the surgical operative notes of Dr.PSIMS and RF in comparison with RCS guidelines for operative notes Observation: Differences were extracted and the information has been graphically represented using Microsoft Excel Bar charts. Recommendations: To print the RCS guidelines proforma in the operative notes of Dr.PSIMS & RF and filling them while writing surgical operative notes To brief all the surgical post graduates regarding the fields that are commonly being missed while writing surgical operative notes Findings: Operative diagnosis was written in 80% preimplementation notes and 100% of post-implementation notes. Pre implementation of RCS guidelines, 78% of operative notes included the names of the anesthetist and the operative staff, 88% included assistant names, and 90% included the name of the operating surgeon. Post-implementation, these numbers increased to 92%, 93%, and 99%, respectively. A total of 10 parameters were looked which would further be elaborated in the discussion. Conclusions: Statistics shows that certain fields in the operative notes are not being filled or not being mentioned appropriately. Hence, certain method should be devised to make sure that all the operative notes criteria given by RCS should be fulfilled in operative notes writing and near perfection was achieved in later re-audits. Well-structured and comprehensive operating details are very helpful. A clear improvement was seen, for example, regarding duration and postoperative orders. The biggest improvements were seen in key areas such as DVT prevention.
I graduated in 2020 and finished MBBS. I went on to work in Covid Intensive units for about a year. I cleared the MRCS Part A and B and further went on to be a member of the Royal College of Surgeons of Edinburgh. I also have completed my diplomas in teacher training as well as Leadership and management. I am currently working in the United Kingdom as a junior clinical fellow.
