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This study examines the value of a proforma in improving the standards of orthopaedic operation notes.

The standard of operation notes in orthopaedic surgery is notoriously poor. This has clinical, medicolegal and research implications. There is no published study on the influence of a proforma on the quality of orthopaedic operation notes.

An audit of the quality of operation notes in the orthopaedic department of Chesterfield and North Derbyshire Royal Hospital was undertaken. 1, 928 cases were identified from theatre log books and 88 randomly selected casenotes were scrutinised by a single observer for the legible inclusion of parameters based on Royal College of Surgeons guidelines. An operation note proforma was devised and used routinely over a period of six weeks. The effectiveness of the proforma was assessed by examining operation notes randomly selected from the procedures performed during that period. Identical parameters were assessed. Results from the two groups were compared and statistically analysed using the Wilcoxon signed ranks test. To investigate the longer term impact of proformas an identical audit was undertaken in a neighbouring unit in which a proforma had been in use for five years.

Following introduction of the proforma in Chesterfield there was a statistically significant increase in the inclusion of the assessed parameters (p=0. 001). Criteria such as the patient ID number, pre-op diagnosis, tourniquet use and time, prophylactic antibiotic administration, prosthesis details and post-op instructions showed a marked improvement. No parameter showed a significant reduction in its documentation rate. The results from Rotherham were comparable to those achieved following the introduction of the proforma in Chesterfield.

This study clearly demonstrates the effectiveness of a proforma in improving the standard of operation notes. The results from Rotherham suggest that high standards can be maintained long after the introduction of the proforma. We recommend the routine use of operation note proformas in orthopaedic surgery.

The abstracts were prepared by Mr Simon Donell. Correspondence should be addressed to him at the Department of Orthopaedics, Norfolk & Norwich Hospital, Level 4, Centre Block, Colney Lane, Norwich NR4 7UY, United Kingdom