An audit of operation notes within a General Surgery department at a tertiary care hospital

Objective: to check the quality of operative notes within general surgery department at the shaikh zayed hospital lahore,pakistan materials & methods: this was a prospective audit,consisting of 200 operation notes in each audit cycle (2 audit cycles),randomly picked during 5 months time from 1 st july 2012 to 1st november 2012. good surgical practice by the royal college of surgeons of england was used as the standard for this audit. during the first audit cycle notes of 200 patients were studied. based on the results of first audit cycle certain recommendations made,changes implemented and then 200 more operation notes audited in second audit cycle to see the results after changes. results: the results of first audit cycle clearly showed that our operation notes were inadequate in certain areas as time of operation,nature of operation (emergency/elective),and signature. after implementing the changes based on our recommendations the second audit cycle's results showed tremendous improvement. conclusions: this study shows that our operative notes were not up to the mark initially. but after proper training of doctors and providing them awareness about the importance of post-operative notes,according to the latest guidelines,improvement have been found in all parameters of operation notes and now our operation notes fulfill the criteria set by good surgical practice 2008.