Improving Operation Notes and Postoperative Care: An Audit of Current Practice. Issue 5 (May 2015)

• Record Type: Journal Article
• Authors: Whitehead-Clarke, T; Varma, N; Hadjimichael, A; Gillham, F; O'brien, K
• Is Part Of: Journal of perioperative practice. Volume 25:Issue 5(2015)
• Page Start: 107
• Page End: 111
• Publication Date: 2015-05
• Subjects: Operation note -- Postoperative care -- Multidisciplinary team -- Guidelines; Operating room nursing -- Periodicals; 617.9192
• DOI: 10.1177/175045891502500503
• Languages: English
• ISSNs: 2515-7949

Abstract

The operation note is the single most important document in surgical practice. Ninety one operation notes were assessed on their adherence to guidelines, as well as their legibility and ability to inform postoperative care; as judged by five different healthcare professionals. Results showed a deficiency in essential information and poor legibility overall. Re-audit of 103 operation notes after intervention showed an improvement in nearly all criteria measured. The results indicate that education about current guidelines and an increase in word processing of operation notes improves quality of documentation, and therefore of postoperative care.