Clinical audit of operation notes at the Department of Surgery, Addis Ababa University

Background Operation notes capture the key findings and details of a surgical procedure and are critical to its safety. The Royal College of Sur­geons of England has set an internationally accepted standard for elements of quality operation notes, but no prior research has considered the conformity of Ethiopian teaching hospitals with these standards. Methods A cross-sectional sample was collected at 2 Addis Ababa University teaching hospitals: Menelik II Hospital (MIIH) and Tikur Anbessa Specialized Hospital (TASH). Guided by the 2014 best practice guidelines released by the Royal College of Surgeons of England (RCSE), we retrospectively analysed the data of patients who underwent surgery between 1 August and 31 October 2017. Results All notes (n=348) were handwritten. At both hospitals, operative findings, anaesthesia details, patient position, and incision type were documented >90% of the time. Residents wrote 98% of the notes at MIIH and 91% of the notes at TASH. Surgeons and as­sistants were identified in >96% of the notes from MIIH and TASH, while anaesthesia team members were identified in 88.5% and 5.7% of the notes from MIIH and TASH, respectively. Gauze and instrument counts were documented in 81.2% and 69.5%, and clo­sure technique was described in 71.8% and 52.3% of the notes from MIIH and TASH, respectively. The operation note templates at both hospitals did not include fields for effective antibiotic prophylaxis, deep vein thrombosis prophylaxis, or estimated blood loss. Conclusions Operation notes in the studied hospitals were both incomplete and below the standards described by the RCSE guidelines, with specific concerns being insufficient documentation of technique and support staff, and missing documentation of antibiotic prophylaxis and blood loss. We recommend that Addis Ababa University implements a new operation note format incorporating RCSE requirements, increase the level of supervision provided by senior surgeons for notetaking, and improve surgical documen­tation training in the residency curriculum.