Abstract
INTRODUCTION: Comprehensive and accurate documentation is paramount in ensuring patient safety, and continuity of care, and casts the foundation for auditing practice and creating research. Unfortunately, a lack of documentation has been reported globally. This study aims to challenge current practices and ensure high-quality documentation. METHODOLOGY: The study appraised 100 operation notes completed within a tertiary, regional ENT department against the published guidance. Following an inquiry into the findings, the operative note proformas were modified in alignment with the Royal College of Surgeons (RCS) published standards for the quality of operative notes. A further 100 operation notes were audited. Rates of compliance before and post implementing the intervention were compared. Non-parametric data were analyzed using Fischer's exact test, with P < 0.05 considered to be statistically significant. RESULTS: Upon auditing of operative note completeness against the set criteria, the use of a comprehensive operative note proforma significantly refined the quality of documentation and adherence to the published standards (P < 0.00001). CONCLUSIONS: This study displayed the lack of adherence to the RCS standards about the quality of operative notes within our center. The adoption of a modified proforma which incorporates the 18 criteria defined by the RCS resulted in improved conformance to published standards and a higher quality of documentation. This study corroborates the RCS framework as an effective tool in recognizing deficient practices and areas of improvement. Through compliance with published standards, a higher quality of documentation is attained, contributing to patient safety, clear continued communication, and support of clinical governance.