Surgical Operative Note Report

Transcription

1 Surgical Operative Note Report Quality Management Department Page of 0

2 Contents:. Introduction Related JCI standards: Performance of Operative report documentation in THE HOSPITAL Findings: Recommendations & Action plan:... 0 Page of 0

3 . Introduction Surgery carries a high level of risk, and therefore it should be carefully planned. And proper documentation is an important mean to facilitate continuing care. Ideally, files for patients undergoing a surgical procedure should contain:. A preoperative note, explaining the need for the surgery and the current medical condition of the patient, and the offered surgical procedure.. An operative report or a brief operative note, that describes the surgical procedure and gives details enough to the post operative team to continue the medical care provided to the patient according to the plan and expect any adverse outcome of the surgery. 3. Post Operative care plan note. This report focuses on the Operative report documentation process in THE HOSPITAL, taking in consideration that preoperative documentation and the minimal requirements for each document is not clearly identified in the hospital policy. Purpose of this report is to highlights areas for improvement & guides the stakeholders to better performance & compliance with the JCI standards and raising the need to have a written policy for preoperative assessment and documentation.. Related JCI standards: Standard ASC.7 Pre-Operative note: Because surgery carries a high level of risk; its use is carefully planned. The patient s assessment(s) is the basis for selecting the appropriate surgical procedure. Assessment(s) provide information necessary to Select the appropriate procedure and the optimal time; Perform procedures safely; and Interpret findings of patient monitoring. Procedure selection depends on the patient s history, physical status, and diagnostic data as well as the risks and benefits of the procedure for the patient. Procedure selection considers the information from the admitting assessment, diagnostic test, and other available sources. The assessment process is carried out in a shortened time frame when an emergency patient needs surgery. The surgical care planned for the patient is documented in the patient s record, including a preoperative diagnosis. The name of the surgical procedure alone does not constitute a diagnosis. The surgical care planned for the patient is documented in the patient s record, including a preoperative diagnosis. The name of the surgical procedure alone does not constitute a diagnosis. Page 3 of 0

4 5. Position 6. Sterilization and draping 7. site of incision 8. operative details 9. closure 0. Post operative Diagnosis. Specimen/s sent to Pathology. Transfusion Units Used 3. Intra Operative Complication 4. Estimated Date of Discharge 5. Post Operative Instructions. Findings: The operative report template in the hospital only meets the requirements of JCI for a brief post operative report and not complete operative report were detailed operative procedure is required to be written. It should be noted that the brief post operative report is the minimal requirement for JCI and that the name of the operative procedure is one of the items that needs to be present in the report while the THE HOSPITALalam template does not have planned space for the procedure name and most surgeons use the space designated for procedure description to write the operation name only. In the 3 cases reviewed the collective completeness of documentation was only 74% with high variability between individual surgeons. Figure : Number of cases reviewed per surgeon Number of cases per surgeon Abd El Hamid Eissa Adel Hossny Ahmed Hatem Amr Aboul Ella Amr Ayad Amr Mansy Ashraf Abo El Fattouh Hamed Kadry Figure : collective report completeness as per report item: Page 6 of 0

5 Operative Note Report 4. Recommendations & Action plan: Areas for improvement Actions required Justification Report: Template name Operative category Procedure name Sterilization and draping Pathology specimen Policy Education and orientation Change template name to Brief post operative report Adding urgent surgery to the available options Adding a designated space for the surgical procedure name Add a yes and no check marks. Adding a space for detergent used In addition to the current yes and no check box a title of if yes please specify type of specimen) A detailed policy of the minimal requirements of the brief post operative report is required. Also the feasibility of having a detailed operative report at this point until the EMR is officially lunched should be studied and questioned Orientation lectures should be given to care givers explaining the importance of operative report According to JCI this template only qualifies as a Brief post operative report. Elective surgery is the surgery scheduled in advance. Urgent surgery is one that can wait until the patient is medically stable, but should generally be done with in 4hrs. Emergency surgery is one that must be performed without delay Minimal requirement by JCI Facilitate post operative care Facilitate billing procedures Many patients do develop post operative skin problems with povidone-iodine products (Betadine). Documentation helps early detection of cause of the problem and prober treatment It is important to mention the type of specimen to insure correlation and detection of pathology report errors during follow ups. Policies and procedures outlines the duties and responsibilities of each care giver and allow auditing and performance appraisals, and hence allow training and improvement. Due to high turnover of surgeons the hospital is always acquiring new surgeons from different Page 0 of 0