# Improving the Quality of Operative Notes in Vascular Surgery: A Retrospective Analysis

## TL;DR

This study shows that using checklists, education, and digital tools can significantly improve the quality of surgical notes in vascular surgery.

## Contribution

The study introduces a practical, multi-step intervention to enhance operative note quality in vascular surgery.

## Key findings

- Documentation of dates, procedures, and personnel improved significantly after the intervention.
- The use of a scanner and checklist increased the uploading of operative notes into the digital system.
- Staff education and visual aids led to better compliance with surgical documentation standards.

## Abstract

Background and objective

Missing information or mistakes in patients’ medical records, including those related to intraoperative and postoperative information, in an operative note can have profound clinical, ethical, and medicolegal implications. Operative notes should be informative, clear, and inclusive of the necessary data and should be collated immediately following surgery. In this study, we aimed to determine the ways to improve the quality of operative notes in the field of vascular surgery.

Methods

In this retrospective analysis, we compared the operative notes of 32 patients in the Department of Vascular and Endovascular Surgery, University Hospital Galway, against the standard set by the Royal College of Surgeons in Ireland (RCSI) (Code of Practice for Surgeons RCSI, 2018) and presented the results to our departmental staff. To facilitate an improvement in the quality of operative notes, a structured poster checklist was designed and displayed in the operating theatre. Furthermore, a scanner was set up in the operating theatre with clear and easy-to-follow instructions for uploading the operative notes into our hospital’s online and digital patient record system (EVOLVE). An explanatory video was circulated among the staff. Three months after the first cycle, two further retrospective cycles were performed.

Results

A total of 96 patients’ operative notes were analysed. Following the intervention, a significant improvement in documentation was noted concerning the dates; procedures followed; as well as the details of surgeons, assistants, anesthetists, incisions, surgery types, operative diagnoses, complications, additional procedures, tissue details, prostheses involved, closure techniques, postoperative plans, and surgeons’ signatures. We also observed a significant increase in the uploading of the operative notes in the EVOLVE system.

Conclusions

The quality of the operative notes improved considerably after staff education, poster display, and scanner installment in the operating theatre. It is important to have an efficient and well-structured plan to improve the process of operative note-keeping, thereby ultimately enhancing overall patient care.