Enhancing Neurosurgical Practice through Adherence to Operative Note Guidelines: An Audit

Introduction: Comprehensive documentation is a crucial element of surgical procedures. This study aims to evaluate the quality of operative note-writing within a neurosurgical unit in Sri Lanka, ensuring adherence to the Royal College of Surgeons of England guidelines.
Methods: Data was extracted by an audit at the neurosurgical unit of Sri Lanka, pre and post-intervention where an educational program on documentation was conducted and standardised operative note template was introduced. Data was analysed by SPSS software and assessed by Wilcoxon Signed Rank Test.
Results: Initially the signature (1%), prosthesis serial number (1%), estimated blood loss (3%), complications (5%), reasons for extra procedures (11.9%), and name of anaesthetist (19.8%) was minimally documented which significantly improved post-intervention. Post-operative antibiotics and deep vein thrombosis prophylaxis use was also significantly improved similarly (p<0.05).
Conclusion: Educational intervention significantly improved the guideline compliance for operative notes which is recommended to be explored at multiple settings with larger samples.