A CLOSED-LOOP CLINICAL AUDIT ON COMPLIANCE WITH ROYAL COLLEGE OF SURGEONS GOOD SURGICAL PRACTICE IN OPERATIVE DOCUMENTATION: A QUALITY IMPROVEMENT STUDY

Sadia Shoukat; Azra Ahmed; Sakeena Ahmed; Nusrat Jameel; Nazia Azam Yousfani

doi:10.37762/jgmds.13-1.772

Authors

Sadia Shoukat Assistant Professor & Consultant Gynecology and Obstetrics, Suleman Roshan Medical College Hospital, Tando Adam
Azra Ahmed Associate Professor, Department of Gynaecology and Obstetrics, Suleman Roshan Medical College Hospital, Tando Adam
Sakeena Ahmed Assistant Professor, Department of Gynaecology and Obstetrics, Suleman Roshan Medical College Hospital, Tando Adam
Nusrat Jameel Senior Registrar, Department of Gynaecology and Obstetrics, Suleman Roshan Medical College Hospital, Tando Adam
Nazia Azam Yousfani Associate Professor, Department of Public Health, Suleman Roshan Medical College, Tando Adam

DOI:

https://doi.org/10.37762/jgmds.13-1.772

Keywords:

Surgical audit, quality improvement, cesarean section, operative documentation

Abstract

OBJECTIVES

This audit aimed to evaluate compliance with Cesarean section documentation standards and to assess the effectiveness of a standardized pro forma with focused training.

METHODOLOGY

This audit was conducted as a pre- and post-interventional audit from February 10, 2025, to July 10, 2025, in the obstetrics department of Suleman Roshan Medical College Hospital. Using a 17-item checklist based on RCSEng Good Surgical Practice and departmental protocol, we analyzed 120 operative notes before and after implementing a standardized documentation template and operative team education. Compliance rates were calculated as percentages. Statistical comparisons were performed using the McNemar test; p-values <0.001 indicated signifcance.

RESULTS

The initiative signifcantly improved documentation (p<0.001). Documentation of complications increased from 10% to 99%, DVT prophylaxis recording, when applicable, rose from 0% to 100%, and details of operative findings improved from 55% to 99%. Overall, 14 of the 17 audited parameters were documented in over 95% of cases. The audit also encouraged a departmental culture that emphasizes documentation for patient safety rather than merely as an administrative duty.

CONCLUSION

The use of a structured pro forma, combined with training, enhances the completeness and quality of operative notes. This approach not only saves time but also helps ensure that crucial details are not overlooked.

KEYWORDS: Surgical Audit, Operative Documentation, Cesarean Section, Quality Improvement

Downloads

Download data is not yet available.

Metrics

Metrics Loading ...

References

Johnston G, Crombie IK, Alder EM, et al. Reviewing audit: barriers and facilitating factors for effective clinical audit. BMJ Qual Saf. 2023;9(1):23–36. DOI: https://doi.org/10.1136/qhc.9.1.23

Hassan RE, Akbar I, Khan AU, Hameed MB, Raza M, Shah SH, Haroon H, Hanzala RA. A clinical audit of operation notes documentation and the impact of introducing an improved proforma: an audit cycle. Cureus. 2023 Dec;15(12). DOI: https://doi.org/10.7759/cureus.50281

Nasim O, Durrani A, Eskander B, Pantelias C, Gallagher K. A clinical audit of orthopaedic operation note documentation and digitalization of the operative note template: a quality improvement project. Cureus. 2022 Dec;14(12). DOI: https://doi.org/10.7759/cureus.33171

National Patient Safety Agency (NPSA). Review of patient safety incidents in the NHS. 2024.

Royal College of Obstetricians and Gynaecologists (RCOG). Towards Safer Childbirth. 2024.

World Health Organization. WHO Surgical Safety Checklist. Geneva: World Health Organization; 2008. Available from: https://www.who.int/publications/i/item/9789241598552

Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491-9. https://doi.org/10.1016/j.ijmedinf.2025.106202 DOI: https://doi.org/10.1016/j.ijmedinf.2025.106202

Williams N, O’Connell PR, McCaskie A — Human factors, patient safety, and quality improvement. In: Bailey & Love’s Short Practice of Surgery, 27th Edition: The Collector’s Edition. Ch. 13. Boca Raton, FL: CRC press; 2018. p. 1301-19. https://doi.org/10.1201/9781315111087. DOI: https://doi.org/10.1201/9781315111087

The Royal College of Surgeons of England: Good Surgical Practice. (2025). Accessed: https://www.rcseng.ac.uk/-/media/Files/RCS/Standards-and-research/GSP/Good-Surgical-Practice-Guide-2025

Rtiza-Ali A, Houghton CM, Raghuram A, O'Driscoll BR. Medical admissions can be made easier, quicker and better by the use of a pre-printed Medical Admission Proforma. Clinical Medicine. 2001 Jul 1;1(4):327. https://doi.org/10.7861/clinmedicine.1-4-327 DOI: https://doi.org/10.7861/clinmedicine.1-4-327

Lyons R, Payne C, McCabe M, Fielder C. Legibility of doctors' handwriting: quantitative comparative study. Bmj. 1998 Sep 26;317(7162):863-4. https://doi.org/10.1136/bmj.317.7162.863 DOI: https://doi.org/10.1136/bmj.317.7162.863

Khan MU, Ahmed S, Shamim MS, Azhar M, Rehman SU. Operative notes at the surgical units of a tertiary care hospital. Journal of Surgery Pakistan (International). 2010 Jan;15(1):57-9.

Khalid A, Ahmed H, Gilani A, Khan KH, Shahzad MZ, Khan K. Audit of operative notes against Royal College of Surgeons guidelines in a tertiary health care surgical unit in Lahore. Cureus. 2022 Sep 19;14(9). https://doi.org/10.7759/cureus.29313 DOI: https://doi.org/10.7759/cureus.29313

Audit S, in Orthopaedics RC, Blackburn J. Assessing the quality of operation notes: a review of 1092 operation notes in 9 UK hospitals. Patient safety in surgery. 2016 Feb 6;10:5. https://doi.org/10.1186/s13037-016-0093-x DOI: https://doi.org/10.1186/s13037-016-0093-x

Mulwafu W. The quality of hand-written operative notes in a surgical unit at Queen Elizabeth Central Hospital (QECH), Malawi: a prospective completed audit loop study. Malawi Medical Journal. 2018 Jun 30;30(2):86-9. https://dx.doi.org/10.4314/mmj.v30i2.6 DOI: https://doi.org/10.4314/mmj.v30i2.6