Table 1 Results of Compliance with RCSEng guidance for standardisation of intraoperative documentation
Category documented | Freehand op-note (n = 74) | Templated op-note (n = 23) |
|---|---|---|
Date | 72 (97%) | 23 (100%) |
Time | 1 (1%) | 20 (87%)* |
Elective or emergency | 0 (0%) | 23 (100%)* |
Name of the operating surgeon and assistant | 70 (95%) | 23 (100%) |
Name of the anaesthetist | 72(97%) | 21 (91%) |
Operative procedure carried out | 74 (100%) | 22 (96%) |
Incision | 64 (88%) | 22 (96%) |
Operative diagnosis | 74 (100%) | 23 (100%) |
Operative findings | 74 (100%) | 23 (100%) |
Details of closure technique | 73 (99%) | 23 (100%) |
Anticipated blood loss | 1 (1%) | 20 (87%)* |
Antibiotic prophylaxis | 58 (78%) | 22 (96%) |
Detailed post-operative care instructions | 74 (100%) | 23 (100%) |
Signature | 71 (96%) | 21(91%) |
All categories | 0 (0%) | 13 (57%)* |