Total Knee Replacement Operation Notes Audit
Department adherence to BOA and BASK good clinical practice guidelines for total knee replacement operation notes
Results
References
1. British Orthopaedic Association and British Association for Surgery of the Knee. Knee Replacement: A Guide to Good Practice. London: BOA; 1999
2.The Royal College of Surgeons of England. Guidelines for Clinicians on Medical Records and Notes. London: RCSE; 1994
Background
British Orthopaedic Association (BOA) states that ‘good
records are a basic tool of clinical practice.’ (1)
Changes to Practice
RCS England states that medical records are ‘fundamental for clinical care and audit of surgical services.’ (2)
Increased awareness of the BOA and BASK good clinical guidelines on total knee replacements
Aim of Audit
To assess the adherence
Personal reflection amongst staff regarding their individual practice in accordance with the guidelines
of total knee replacement (TKR) operation
notes written at Altnagelvin Area Hospital to the BOA and British Association of Surgery of the Knee (BASK) guidelines 1
Await the introduction of a standardised TKR operation note template
Negative findings:
Recommendations
1. Education on best clinical guidelines may increase adherence
No operation note documented all 15 recommendations
Patients diagnosis not documented in 45%
Component alignment and rotation not documented in 70%
Post surgery flexion range not documented
Prosthesis / implant serial number not found in 1
Tourniquet time not documented in 4
Standards (1)
2. Checklist in orthopaedic theatre for reference
3. Standardised total knee replacement operation note template
Impact on Patients Care
4. Re-audit in 5 months
These recommendations are in place to:
1. Improve patient safety in the post-operative period
2. Aid with future research and the design of new operative strategies and prostheses
3. Contribute the appropriate information to
medico legal cases
- Name of surgeon, assistant and responsible consultant
- Diagnosis and procedure performed
- Incision and additional procedures required to achieve adequate exposure
- Findings
- Soft tissue release procedures
- Significant tissue excision, transposition or augmentation
- Serial numbers of prosthesis and other implants
- Bone grafting
- Details of component alignment and rotation
- Post-surgery flexion range
- Tourniquet time
- Sutures used
- Difficulties / complications encountered and how they were overcome
- Post op instructions
- Surgeons signature and date of op
Methodology
5 month period (1st April - 31st August 2014)
Conclusion
41 patients identified as having TKR using Theatre Management System (TMS) under 4 different orthopaedic consultants (2:7:9:9)
Accurate operation note documentation impacts both patient and physician
14 patients notes unavailable, 27 patients notes obtained
Identified poor adherence to nationally accepted guidelines
Audit proforma was designed using Microsoft Excel as per the recommendations included in the BOA and BASK guidelines
Await implementation of standardised operation note template
Each operation note assessed for inclusion of
each recommendation
Re-audit aiming for 100% accuracy