AB226. 204. The use of proforma documentation in the improvement of the quality of operative notes in orthopaedic surgery
Orthopaedic Poster Session

AB226. 204. The use of proforma documentation in the improvement of the quality of operative notes in orthopaedic surgery

Claire Hevican, Osama Mohammad, Susan May Cleary, Gerald McCoy

Department of Trauma and Orthopaedic Surgery, University Hospital Waterford, Waterford, Ireland


Background: Good Surgical Practice guidelines were published by Royal College of Surgeons (RCS) in 2008 and subsequently in 2014. Compliance with these guidelines has been shown to be variable. We aim to evaluate the use of procedure specific proformas in Orthopaedic Surgery as a means to improve the quality of record keeping.

Methods: We retrospectively compared the standard of 80 handwritten operative notes in the Department of Orthopaedic Surgery to determine if they comply with the standards set by RCS. These notes were assessed by a single reviewer. Proformas were formulated for commonly performed Orthopaedic procedures. Educational intervention was provided in the form of an interactive lecture, as well as written guidance. The audit loop was then closed by assessing compliance with standards following the introduction of a typed, procedure specific proforma.

Results: These notes were assessed by a single reviewer. Proformas were formulated for commonly performed Orthopaedic procedures. Educational intervention was provided in the form of an interactive lecture, as well as written guidance. The audit loop was then closed by assessing compliance with standards following the introduction of a typed, procedure specific proforma.

Conclusions: The introduction of a proforma improved the standard of operative notes both in terms of legibility and the information provided in relation to the case. While it has been shown that compliance with the RCS guidelines is inconsistent among different specialties, the introduction of a specialised proforma for commonly performed procedures may lead to an increase in conformity.

Keywords: Proforma; documentation; uniformity; recording


doi: 10.21037/map.2018.AB226


Cite this article as: Hevican C, Mohammad O, Cleary SM, McCoy G. The use of proforma documentation in the improvement of the quality of operative notes in orthopaedic surgery. Mesentery Peritoneum 2018;2:AB226. doi: 10.21037/map.2018.AB226