DOI: 10.36347/sjams.2013.v01i06.003

Pages: 668-672

Operation notes writing is one of the fundamental parts of the surgical practice. It should be accurate, clear, and informative and contains all the events and steps in the surgical procedure, to be of value when used in further follow up or in medico legal conditions. The objective of this study was to compare the quality of operative notes at Omdurman Teaching Hospital, Khartoum, Sudan, with the standard set by the Royal College of Surgeons, England 2008. A one month retrospective, descriptive study (2013 Jan.1st to 31st) evaluated the operative notes of patients whom had moderate to major surgical procedures. The collected data was analyzed using the SPSS version 20. The study included 216 operative notes. Patient identification (name, age) was absent in more than 60%. Operating surgeon and assistant names were present in more than 90%. In only 3.2%, the procedure was categorized as an elective or emergency. Surgical incision, description of operative findings, operative complications (if any), and details of closure were mentioned in 63.9%, 69.4%, 37.5%, 26.9% respectively. In conclusion, there is significant deficiency in the contents and missing of vital and crucial information may lead to difficulty in further patients’ management and weakness in doctor defense in medico-legal cases.