To assess surgical practice of writing good operative notes using a closed loop audit in a rural medical college

Aim: To assess and audit the quality of operation notes of Department of General Surgery as compared with guidelines laid down by Royal College of Surgeons. If this audit was found to be deficient, an adequate intervention followed by a re-audit would be undertaken to improve the quality of operation note sheets. Method: This is retrospectively prospective study done in the Department of General Surgery of our institute from October 2020 to August 2021. A retrospective audit (Audit 1-October-December 2020) was done to assess the standard of operation notes. When this was found to be deficient in quality, a reformed operation note sheet was devised in accordance with audited pitfalls and due training was carried out. This was followed by a prospective re-audit (Audit 2-June-August 2021) to assess improvement in quality. Result: The results of first audit were found to be very inadequate with mean 82.5% data point inclusion. This was followed by an upgradation in operation note sheet which now had prompts for all the missing data points. The data points such as type of surgery (elective/emergency), which were not captured at all in Audit 1, were captured in 94% of operation note sheets in Audit 2. The training helped significantly improve various low scoring data points such as date and time; name of theatre anaesthetist; operative findings; any extra procedure performed and the reason of the same; and details of tissue removed, added or altered. Conclusion: Close loop audits and revising operation note sheet according to recent guidelines can significantly improve the good surgical practice of writing standardised operative notes.