Every surgical specialty understands how important complete and accurate operation notes are to protecting patient care and producing data for audits and research. Operation notes are the only records of surgery. In addition to being the sole official record of an operation, the operative findings and post-surgical plans they include are an essential channel of communication between medical experts [1].The British Orthopedic Association asserts that "good records are a basic tool of clinical practice" [3], while the General Medical Council [2] recognizes its importance and asserts that taking effective notes is a crucial part of competent medical practice. On the other hand, The National Confidential Enquiry into Perioperative Fatalities found that orthopedic surgical notes were often insufficient in the UK[4]

Additionally, research indicates that a percentage of lawsuits are related to alleged subpar surgical quality, and that inadequate operation notes—primarily those that are unreadable and utilize unclear abbreviations—are frequently a source of vulnerability for the surgeon's defense [5].Using the previously specified keywords, a PubMed search turned up three significant publications. All of these papers were taken into account when writing this one [1,6,7].The Good Surgical Practice guide [8], published by the Royal College of Surgeons of England in 2008, has a section on record keeping. In 2014, it underwent another revision. This section provides recommendations for data that should be documented in order to create complete and in-depth operating notes (Figure 1).

Consequently, following each surgical procedure, it is crucial to take brief, understandable, and accessible notes. This is difficult to do with handwritten notes, particularly when it comes to legibility. All notes should now, according to the revised 2014 standards, be typed. These criteria were used to evaluate operation notes at the author's institution.

Aims And Objective
This clinical audit's goal is to examine orthopaedic surgical notes to determine if they follow and satisfy the guidelines outlined in the Royal College of Surgeons' Good Surgical Practice.8

GUJRANWALA MEDICAL COLLEGE, GUJRANWALA, PAKISTAN conducted a retrospective clinical audit of operation notes including both elective and trauma procedures from July 2024 to July 2023. A total of 500 operation notes were audited by one reviewer. All of the operation notes were based on the commonly used printed surgical template. The following subheadings were included in the operation record template and the audited operative notes: Patient information, the attending physician, Date, preoperative diagnosis, name of the procedure, anesthetist, scrub nurse, assistant, surgeon, incision, results,

  The post-operative state, drainage, blood loss, urine output, procedure, closure, and post-operative instructions. Every inpatient's operation notes were examined. One observer examined the notes and compared them to the standards outlined in the Royal College of Surgeons, England's Good Surgical Practice guide. The criteria were marked as unfilled in parts that were difficult to read.

In all, eight orthopedic surgeons at the consultant level completed the 500 cases that were reported. After reviewing 500 operation notes, 300 (60%) of them were trauma cases and 200 (200%) fell into elective cases list (Graph 2). While trauma cases varied, elective cases primarily included arthroscopic ACL reconstructions, rotator cuff repairs, knee MCL repair/reconstructions, and lower extremity arthroplasty, Amputations, wound debridement, and implant removal from multiple locations were among elective cases. Trauma cases included mainly fracture fixation surgeries for proximal femur, tibia, humerus, metatarsals, clavicle, phalanx, ankle, femur, distal radius, metacarpals, calcaneum, scaphoid, talus, both bones forearm, and tendon repair/reconstructions.

Each case's surgical notes were handwritten by orthopaedic registrars. As a result, the audited operation notes were written by six orthopaedic specialists with varying levels of experience at the registrar level. In 430 cases (86%) the time was noted, however in 70 cases (14%) the date was not. Every case (100%) had the consultant's name clearly recorded. Nevertheless, there was no record of the name of an assistance in 40 (08%) of the situations where at least one surgical assistant would typically be needed.

There was good adherence to the following: 100% operation documentation, 100% statement of elective or emergency procedure, 93% incision, 90% diagnosis, 85% operative findings, 60% intraoperative problems, 100% closure, and 100% postoperative instructions. Name with signature (88%) and name with 100%, respectively (Figure 3). Information on identifying a prosthesis or implant is typically included on the same page, close to the end of the remarks, but not in the pro forma that is sent. It is concerning that 16% (80 cases) of the handwritten notes contained illegible sections.