Self-assessment of operation notes writing amongst residents in a teaching hospital

Abstract

Context: Operation note writing is an integral part of the surgical procedure and chronicles the details surrounding it.
Objective of the study: Is to determine the level of adherence of the surgical residents to standard guidelines on operation note writing.
Subjects and Methods: This is a cross-sectional survey of residents in the department of surgery, University of Benin Teaching Hospital, Benin City, using an anonimised self-administered questionnaire, which was adopted from the Royal College of Surgeons guidelines on operation note writing.
Results: Thirty-one residents (19 Senior Registrars and 11 Registrars) were sampled. 51.6% of respondents were 1year or less in training. 71.7% of respondents regularly write operation notes, however 90.1% of respondents reported that the first assistant wrote operation notes; while 74.2% reported that they adhere to standard guidelines operation note writing. Date, name of surgeon and assistants, type of operative procedure, incision and findings were universally reported amongst respondents, whereas names of scrub nurses, time, prosthesis serial number, deep venous thrombosis and antibiotic prophylaxis were poorly reported. Only 3 respondents scored 100% with the mean score of 75.4% of identified parameters in the guideline used.
Conclusion: Training on operation note writing should be entrenched to ensure proper adherence to standard guidelines. Formative assessments of the process are imperative to improve compliance.