Audit on Completeness of Operative Notes Documentation at a Teaching Hospital in Lahore Pakistan

Abstract

Objective: This study employed a baseline internal audit design to assess completeness of operative notes documentation at a teaching hospital in Lahore Pakistan.

Methods: This observational cross-sectional retrospective audit study utilized a standardized checklist to assess completeness of operative notes, drawing on guidelines from the Islamabad Healthcare Regulatory Authority, Punjab Healthcare Comission and the Royal College of Surgeons, after ethical approval from Institutional Ethical Review Committee of Azra Naheed Medical College, Superior University Lahore Pakistan. The audit reviewed all medical records of Department of Surgery and allied specialties from April to June 2025. A total of 227 records were retrieved; however, 24 records were excluded due to missing or damaged operative notes. The audit was conducted on 203 operative notes. The results were analyzed using SPSS version 23.

Results: A total of 203 records were assessed. Key findings included high compliance in date (191, 94.1%) and time of procedure (188, 92.6%) but patient identification was documented in only 28 (13.8%). Names of surgeon and assistant (203, 100%), operative finding (201, 99.0%), doctor signature (197, 97.0%), name of operative procedure (196, 96.6%), operative diagnosis (186, 91.6%) and details of tissue removed, added or altered (183, 90.1%) were reasonably well documented. There were gaps in type of elective/emergency procedure (54, 26.6%), prosthesis use (44, 21.9%), any extra procedure performed with reason (36, 17.7%), anticipated blood loss (32, 15.8%), complications encountered (19, 9.4%) and DVT prophylaxis (07, 3.4%).

Conclusions: While some components of operative notes were well-documented, deficiencies persist in areas critical to patient safety and quality care. Continued measures such as revising the operative notes form, training sessions, regular audits and feedback are needed to uphold and enhance documentation practices.