Publication:
Effectiveness of Audit and Feedback in Improving the Quality of Operative Notes - A Retrospective Observational Study

creativeworkseries.issnISSN (Print) : 1993-2979 | ISSN (Online) : 1993-2987
dc.contributor.authorMaharjan, Leison
dc.contributor.authorSinghal, Aditya
dc.contributor.authorGuragain, Rajendra PS
dc.date.accessioned2026-04-07T09:21:57Z
dc.date.available2026-04-07T09:21:57Z
dc.date.issued2019
dc.descriptionLeison Maharjan, Aditya Singhal, Rajendra PS Guragain Department of Otorhinolaryngology and Head and Neck Surgery, Maharajgunj Medical Campus, TU Teaching Hospital, Institute of Medicine
dc.description.abstractABSTRACT Introduction Surgeons must maintain detailed and accurate operative notes as it is important not only for safe patient care but also for research, audit and medicolegal purposes. But literature has shown that many operative notes are incomplete and illegible. Audit and feedback is a useful strategy to improve such practices which our department has been following. Our aim is to study its effectiveness by comparing the quality of operative notes of 2016 with that of 2014. Methods Total 96 operative notes, 48 each of the year 2014 and 2016 were studied under 22 parameters including 18 suggested by “Good Surgical Practice” guideline. Each operative notes was analyzed by a single observer for completeness. Parameters of the operative notes of two different years were compared and given the status of either improved, deteriorated or unchanged. Results Only parameters related to patient identification, date, surgeon’s fullname, postoperative plan were complete in both the years. In comparison to earlier year, in 2016 improvement was seen in parameters such as postoperative diagnosis, details of tissue removed, authors details, closure details, operation time and operative difficulties/complications and deterioration was seen in hospital number, preoperative diagnosis, procedure, fullname of anesthetist, fullname of scrub nurse, operative findings and signature of the surgeon. Conclusion Improvement in the quality of the operative notes was not adequate with audit and feedback strategy alone. Hence to increase the effectiveness, other methods such as computerized operative notes and aide-memoire should also be introduced. Keywords: Audit, feedback, operative notes, surgical notes
dc.identifier.urihttps://hdl.handle.net/20.500.14572/5698
dc.language.isoen_US
dc.publisherInstitute of Medicine
dc.subjectAudit
dc.subjectfeedback
dc.subjectoperative notes
dc.subjectsurgical notes
dc.titleEffectiveness of Audit and Feedback in Improving the Quality of Operative Notes - A Retrospective Observational Study
dc.typeArticle
dspace.entity.typePublication
local.article.typeOriginal Article
oaire.citation.endPage78
oaire.citation.startPage75
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relation.isJournalIssueOfPublication.latestForDiscoveryf8b226a3-5ec6-494c-9a5e-17eb5249fda5
relation.isJournalOfPublicationa9ba45d9-ee33-4a6b-b1fc-6626b87eec6c

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