Audit Of Operation Notes In Plastic And Reconstructive Surgery Unit All Africa Leprosy Tuberculosis And Rehabilitation Training Center (alert) Hospital

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Introduction: High quality operation notes are one of the most crucial parts of patient care as it rnis a means of communication among professionals, source of data for audits and researches, and a source of information in court. The Royal College of Surgeons of England has produced arnguideline in 2014 that outlines the minimum standards that need to be documented on operationrnnotes. This study aims to assess the adherence of ALERT hospital plastic and reconstructive unitrnto these guidelines. rnObjectives: To evaluate operation notes in the plastic and reconstructive unit of ALERT hospitalrnagainst RCSEng GSP 2014 standards, identify causes of incompleteness and suggest possiblernways of improvement in the quality of operation notes. rnMethods: The study is conducted, plastic and reconstructive unit of ALERT hospital. It is arncross sectional retrospective study conducted using stratified random sampling of 341operationrnnotes written since April 1, 2020, supplemented by survey questionnaire administered to 22rndoctors (consultants, fellows and residents) to assess their experience and opinion regardingrnoperation note standards. rnResults: None of the RCSEng GSP 2014 standards were consistently documented. Only 3rnstandards were documented in more than 90% of operation notes. Most operation notes werernwritten by residents. Survey questionnaire administered results showed the participants believernthat lack of quality of operation notes affects follow up and future interventions for patients.rnMore than 95% of the respondents reported that they do not write all the standards consistentlyrnand most commonly attributed reasons are absence of formal education on the subject andrnoperation note proforma incompleteness according to the standard. Among the measuresrnsuggested by the survey participants to improve the quality of operation note includernintroduction of formal teaching about operation note writing, updating the existing operationrnnote proforma to include the RCSEng GSP 2014 standards and educating the staff about thernstandards. rnConclusion: Operation notes in plastic and reconstructive surgery unit of ALERT hospital arernnot up to standard per RCSEng GSP 2014 guideline. Formal education, update of existingrnoperation note proforma, posting aide memoires in the operation theatres and clinical educationrnof the staff about the standards are some of the proposed solutions to improve the quality of the rnoperation notes.

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Audit Of Operation Notes In Plastic And Reconstructive Surgery Unit All Africa Leprosy Tuberculosis And Rehabilitation Training Center (alert) Hospital

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