Table 2. Comparison of surgical operation note documentation parameters before and after intervention based on RCS guidelines.
This table presents a comparative analysis of documentation compliance for key surgical operative note parameters between the first and second audit cycles, each comprising 50 surgical cases. The checklist used was derived from the Royal College of Surgeons (RCS) guidelines. The "improvement" column represents the percentage point increase in compliance between the two cycles. Statistical significance was evaluated using the chi-square (χ²) test. A p<0.05 was considered statistically significant. Notable improvements were observed in several critical parameters, indicating the effectiveness of structured interventions, such as standardized proformas and staff training.
DVT: deep vein thrombosis
| Parameters | First cycle (n=50) | Second cycle (n=50) | Improvement | Chi-square (χ²) | p-Value |
| Patient identification | 1 (2%) | 50 (100.0%) | 98.0% | 92.20 | <0.0001 |
| Date and time | 28 (56%) | 49 (97.8%) | 41.8% | 22.59 | <0.0001 |
| Type of procedure | 8 (16%) | 50 (100.0%) | 84.0% | 69.01 | <0.0001 |
| Surgical team information | 38 (76%) | 49 (97.8%) | 21.8% | 8.84 | 0.0029 |
| Anesthetist information | 29 (58%) | 40 (80.4%) | 22.4% | 4.68 | 0.0306 |
| Performed surgical procedure name | 44 (88%) | 50 (100.0%) | 12.0% | 4.43 | 0.0353 |
| Type of incision | 32 (64%) | 42 (84.8%) | 20.8% | 4.21 | 0.0402 |
| Preoperative diagnosis | 4 (8%) | 47 (93.5%) | 85.5% | 70.59 | <0.0001 |
| Operative findings | 39 (78%) | 46 (91.3%) | 13.3% | 2.82 | 0.0929 |
| Complication encountered | 26 (52%) | 18 (37.0%) | -15.0% | 1.99 | 0.1585 |
| Extra procedures and rationale | 10 (20%) | 11 (21.7%) | 1.7% | 0.00 | 1.0000 |
| Tissue details stated | 27 (54%) | 38 (76.1%) | 22.1% | 4.40 | 0.0360 |
| Closure technique | 23 (46%) | 41 (82.6%) | 36.6% | 12.54 | 0.0004 |
| Anticipated blood loss | 5 (10%) | 24 (47.8%) | 37.8% | 15.74 | 0.0001 |
| DVT prophylaxis (if applicable) | 0 (0%) | 10 (19.6%) | 19.6% | 9.00 | 0.0027 |
| Antibiotics prophylaxis | 7 (14%) | 32 (63.0%) | 49.0% | 24.21 | <0.0001 |
| Identification of prosthesis used | 7 (14%) | 13 (26.1%) | 12.1% | 1.56 | 0.2113 |
| Postoperative care instructions | 0 (0%) | 38 (76.1%) | 76.1% | 58.11 | <0.0001 |
| Surgeon’s signature | 20 (40%) | 32 (63.0%) | 23.0% | 4.85 | 0.0277 |