Assessment of manual operation note documentation practice: a cross-sectional study

Background: Operation note documentation captures the key findings and subtle elements of a surgical strategy and is crucial for patient safety. Poor operation note documentation can negatively influence postoperative patient care. This study aimed to assess manual operation note documentation practice. Methods: An institutional-based, cross-sectional study was conducted from 30 March to 30 April 2022, on 240 operation notes of patient data. Data were entered and analyzed by SPSS version 20. According to the RCSE, the Royal College of Surgeons of England, the practice of operation note documentation was rated excellent for each variable when it met 100%, good if it met more than 50%, and poor if it met less than 50% of the operation notes of patient data. Results: All operation notes (n=240) were handwritten. The practice of manual operation note documentation was deemed excellent in two (7.69%), good in 18 (69.2%), and poor in six (23.1%). Residents wrote 84.2% of the operation notes and surgeons and assistants were identified in greater than 94% of the notes, while anesthesia team members were identified in 90.8%. Estimated blood loss was documented in 4.2% of the notes, and the closure technique was described in 64.2%. The operation note templates did not include antibiotic prophylaxis, runner nurse name, or gauze and instrument counts. The urgency of the surgery and time of documentation had a negative relationship, and the seniority of the operation note writer had a positive relationship with manual operative note documentation practice. Conclusions and recommendations: Compared to the standard, all operation note documentation was incomplete and below the standard. We recommend that this comprehensive and specialized hospital administrator implement a new format for operation notes that incorporates RCSE requirements.


Introduction
Operation notes documentation captures the details of a surgical procedure, counting individual details of the patient, indications for surgery, technical descriptions, intraoperative findings, and postoperative instructions [1] .Clinical record keeping is an essential component of providing quality healthcare [2] .
Both from a therapeutic and legal point of view, the quality of operative notes is vital to improving communication between distinctive healthcare experts [3] .Because operative notes are frequently presented in legal malpractice cases, studies have shown that up to 45% of operative notes are medico-legally indefensible [4] .
Evidence from the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) reveals that poor documentation can negatively influence postoperative care at several stages, for example immediately postoperatively, predischarge, and subsequent patient care [5] .
The General Medical Council recommends that accurate, comprehensive, and legible records be maintained for every patient by the surgeon [6] .Accurate, legible, and detailed operation notes are of great importance in all surgical specialties, not only for patient care but also for providing information for research, audit, postoperative management, and medico-legal purposes [7] .Handwritten notes are still used worldwide; however, establishing their legibility can often be a major drawback [8] .
An audit conducted in Kuwait by Sweed et al. [9] illustrated that 20% of the operative notes they looked at contained illegible parts, were incomplete, and included confusing abbreviations.Audits of operation quality regularly identify failure to meet the required standards [3,[10][11][12][13] .
In 2009, the National Patient Safety Agency (NPSA) looked in detail at the causative factors in patient safety incidents (PSIs) [14] .

HIGHLIGHTS
• All operation notes were handwritten.
• Most of the operation note was incomplete and did not adhere to the standard.• Adherence to the RCSE (Regal College of Surgeons of England) criteria of 7.69% was deemed excellent.
Human factors were a major contributor to PSIs, and, in particular, communication issues were highlighted.Written communication plays a critical role in all perspectives of mistakes, with illegible handwriting and vague instructions highlighted as common issues [15] .To improve our clinical practice, there is a need to adopt a standardized way to record operative notes so that our records contain all the details fundamental to delivering patients the best possible care.Although there are limited standardized guidelines in Ethiopia relating to operative notes, there are worldwide guidelines that are in use and are well-perceived, such as those set by the Royal College of Surgeons of England (RCSE) [13] .
The Good Surgical Practice guidelines published by the RCSE recommend that operation notes be legible, typed (if possible), and taken with the patient from the working operation theater to recovery and the surgical ward [1] .
Royal College of Surgeon guidelines have mainly identified criteria for operation note documentation for 'good surgical practice' [13] .
Evidence from the NCEPOD reveals that poor documentation can negatively influence postoperative care at several stages, for example immediately postoperatively, predischarge, and subsequent long-term patient care [5] .
As a result, accurate and clear notes benefit the patient by serving as a tool for communication between anesthesiologists and their medical and nursing colleagues [4] .
A few studies have been conducted on operation note documentation in the study setting.Therefore, this study aimed to assess the adherence of operation note documentation against the standards set by RCSE to improve the quality of operative notes and ensure immediate postoperative care, for subsequent management, in hospital care and also for referred as well as respective surgical, nursing, and anesthetic patient care.

Methodology
Ethical clearance was obtained from the institutional ethical review committee.The aim of the study was explained to each study participant, and informed consent was obtained.This study was registered with the UIN research registry and reported following STROCSS (strengthening the reporting of cohort, crosssectional and case-control studies in surgery) criteria [16] .

Study design
An institutional-based, cross-sectional study.

Performed setting
This comprehensive and specialized hospital is among the largest hospitals, with over 500 beds, of which ~200 are surgical beds, including trauma, obstetrics and gynecology, and ophthalmology.
This provides inpatient care, outpatient services, and followup clinics, covering elective and emergency surgery, with six operating theaters, one orthopedic table in one operation room complex, a minor operating theater, and 24-h emergency service.
In this study, we reviewed the operation notes for patients admitted for surgery from 30 March to 30 April 2022, using the updated 2014 RCSE guidelines as a quality benchmark [1] .

Source population
All operation notes are documented in the study area.

Sample population
Operation notes were documented in the study area during the study period.

Sample size
The required sample size was calculated using a single population proportion formula from a previous study (45%) [17] as follows: Assumptions are n is the required sample size, Z is the critical value for normal distribution at a 95% confidence level (1.96), W = 0.05 (5% margin of error), and E is the best estimate of the population proportion.
The correction formula was used.Since our sample population (N) is less than 10 000 (i.e. on average, 450 surgeries are done per month in the all-operation room in the study area), we use the following formula to calculate the exact sample size: Finally, a total of 240 randomly selected operation notes were reviewed in this study and analyzed prospectively for completeness and appropriate documentation.

Dependant variable
The practice of manual operation note documentation.

Independent variable
Urgency of the surgery, Seniority of surgeons who wrote operation notes, time of documentation.

Operational definition
The practice of manual operation note documentation was deemed excellent if met at 100%, good if it met at > 50%, and was deemed poor if met at <50% of each variable of patient data [17] .

Data collection method
The principal investigator and one bachelor of degree Anesthesia student reviewed 240 operation notes from the record written by the operating surgical team over 1 month.
The data were checked, coded, entered, and cleaned using SPSS version 20.A descriptive statistical analysis was performed.Results were expressed in frequency tables, charts, and percentages.
All the data were collected based on the RCSE operation note writing guideline standard format (Tables 1 and 2) and directly changed into question forms with three integral checking components: 'Yes', 'No', and 'partial'.

Results
From randomly selected and reviewed 240 operation notes and we found that they were not utilized to type the operation notes.Residents wrote about 84.2% of operation notes and consultant surgeons wrote only 15.8% of notes.Most of the operation notes 180 (75%) were documented during the night shift.In our setup during the night shift, emergency surgery was done.
The date of the surgery was documented in almost all of the operation notes reviewed (99.2% of notes); also, the names of the operating surgeon and assistants were consistently documented (above 90% of notes documented the names of healthcare providers in the operating theater).Even though none of the operation notes included the names of runner nurses.
While the primary provider was consistently documented, this was not consistent for other participants.The names of the anesthetists were documented in 90.8% of the notes.Even though the type of anesthesia and the intraoperative findings were documented in more than 95% of the notes, the position of the patient, the type of incision, the operative diagnosis, and the intraoperative findings were documented in less than 75% of the notes (Tables 3 and 4).Also, the occurrence or nonoccurrence of complications was inconsistently documented, being included in 5.9% of the notes.
The documentation of whether additional procedures were performed other than those initially planned was similarly inconsistent, occurring in 10% of notes.The details of tissue removal and wound closure were documented in 86.7% and 64.2% of notes, respectively.The urgency of the procedure was reported in 1.7% (n = 240) of the notes, and gauge and instrument counts were not documented in all notes.
Only 7.69% of the RCSE criteria (patient hospital number and operating surgeon name) and adherence to RCSE operation note standards were deemed excellent (100%).However, 23.1% of the RCSE criteria (antibiotic prophylaxis, anticipated blood loss, used instrument count, any problems or complications, the runner nurse's name, and the procedure's urgency) did not adhere to RCSE operation note standards (50%).
A postoperative plan was included in nearly all of the operation notes (94.2%).The majority of the operative notes  were written by the junior resident (62.5%; n = 150), followed by the senior resident (21.1%; n = 54) and the consultant (15.8%; n = 38).There are also areas that were only partially documented, such as patient detail documentation, wound closure technique, and the identity of the writer of the operation note (Table 5).

Discussion
Accurate and complete operative notes are considered a critical element of quality assurance in surgery, and it is among the most important skills required of a surgeon, as appropriate documentation of a surgical procedure is vital for postoperative patient care [18] .The fact that no operation note was appropriately filled out in this study is a reflection of the suboptimal quality of documentation of perioperative details of patients, and this calls for improvement.Audits from Nigeria and other parts of Africa have demonstrated similar, and in some instances, poorer, results [19][20][21] .Those from developed countries, however, showed marginally better results [22,23] .Incomplete operation notes hinder postoperative patient management, as notes written with illegible handwriting or those that use nonstandard abbreviations, for example can confuse healthcare providers responsible for further patient care [4] .Even though RCSE guidelines provide an accepted international standard, the operation notes analyzed in this study had not consistently confirmed.
Moreover, incomplete notes are not useful in medico-legal cases, with one study reporting that up to 45% of operation notes cannot be used to support a defendant in a court of law [4] .In this study, the date of the surgery was documented in almost all notes (99.2%), which is similar to findings from other studies in Africa and elsewhere (92.6-99%) [18,20] .
RCSE guidelines stipulate that both date and time should be recorded in operation notes; this was consistently documented at the hospital under study.Contrary to this, the time of surgery was commonly omitted in operation notes evaluated by investigators in Nigeria and Pakistan [24,25] ; however, a study conducted in Sudan found that the time was documented in 81% of notes [20] .
In the current study, the names of surgical team members were documented fairly consistently in the notes, but the runner nurses were missed from all of the notes.This may have been due to differences in the formatting of the operation note forms used.A study from Sudan found that the names of the anesthetists and scrub nurses were rarely documented (13.9 and 0.9%, respectively) [20] ; in comparison to this, our audit found that the scrub nurses' and anesthetists' names were mentioned in above 90% of notes.
This demonstrates an opportunity for a revised operation record sheet format, which, if linked to a preoperative safety checklist, would facilitate the introduction of all surgical team members and the documentation of their names [26] .
In this study, the type of anesthesia and intraoperative findings were documented in more than 90% of the notes that we investigated, and this was comparable with previous studies [26] .Position of the patient, type of incision, operative diagnosis, and closure technique were less frequently documented, which was lower than the rates observed in the previously mentioned studies conducted in Nigeria (82%) [25] and comparable with the study conducted in Pakistan (69%) [24] , but higher than the proportion observed in the study carried out in Sudan (26.9%) [20] .
According to our findings, the majority of operation notes were written by surgical residents; this is concerning because previous research has shown that trainees struggle to produce high-quality operation notes without assistance [27] .According to the Pakistan study, the majority (86.5%) of operation notes were also written by trainee surgeons [24] .While globally, only 10-18% of institutions offer operative note writing as part of their residency program curricula, and most senior surgeons have never received such training, it has been shown that teaching operative note writing has improved the quality of documentation [18,28] .Although all of the operation notes were assessed as legible and handwritten in this study, it has been shown that handwritten operation notes are often illegible [29] , while typed electronic notes have demonstrated full legibility [30,31] .For this reason, RCSE guidelines recommend that operation notes be typed whenever possible.
RCSE guidelines also call for the documentation of anticipated blood loss, antibiotic prophylaxis, and a total used instrument count, all of which were not regularly recorded in the operation notes that we analyzed.These omissions are particularly troubling, as a lack of properly documented instrument counts and antibiotic prophylaxis increases the likelihood of adverse safety incidents [32] , and a lack of blood loss estimation creates obstacles for adequate postoperative transfusion care if needed.
These omissions call for the systematization of both the body of the operation note form and of postoperative care orders linked to the operative findings.Incorporating these elements into a new format for operation notes, again linking to a preoperative safety checklist if possible, would align our operation notes with the RCSE's 2014 operation note guidelines.

Limitation
As a limitation, this study was conducted in an observational study design, and this may limit nationwide operation note guideline development.

Conclusions
The practice of manual operation note documentation was below the standards recommended by the 2014 RCSE guidelines.Completion and documentation of surgical procedures in the study area operation sheets were excellent in terms of recording date, patient's identity, surgeon, intraoperative finding documentation, procedure name, and postoperative plan.However, improvement is needed in documenting the urgency of the procedure, the occurrence or not occurrence of complications, the used instrument count, whether or not any extra procedures were conducted, and the estimated blood loss.

Recommendations
We suggest that hospital administrators should use the RCSE guidelines as a baseline to standardize operation note-taking, with some modifications as needed following the guidelines, and should implement improved, standardized operation notes with clear, itemized sections for the preoperative state of the urgency of the procedure, team members, the date and time of surgery, intraoperative procedure details, and postoperative care instructions, as outlined above.
was the total sample size.

Table 1
Sociodemographic variables for the practice of manual operation note documentation

Table 2
Procedure-related variables for the practice of manual operation note documentation RCSE, Royal College of Surgeons of England.

Table 3
The relation of sociodemographic variables with the practice of manual operation note documentation (n = 240)

Table 4
The relation of procedure-related variables with the practice of manual operation note documentation (n = 240)